Exercise Complications In The Setting Of Cardiac Rehabilitation

HISTORY: An 84-year-old male experienced a sudden cardiac event during week nine of phase II cardiac rehabilitation (CR). Medical history is notable for percutaneous stenting (June 14th, 2022; referring diagnosis) three weeks prior to initiating CR, chronic diastolic heart failure (55% ejection fraction), left ventricular hypertrophy, aortic stenosis, and neurocardiogenic syncope. Patient was considered an intermediate risk for a cardiac event per AACVPR event risk stratification. After exercising on the rowing ergometer, the patient called to an exercise physiologist. Upon staff arrival he collapsed into their arms and lowered to the floor. The patient reported no symptoms in the weeks prior, same day of the event, or immediately prior to the arrest. PHYSICAL EXAMINATION: The patient was found to be pale, diaphoretic, had agonal breathing and no palpable pulse. ACLS protocols initiated immediately. Patient shocked initially with 200 J for ventricular fibrillation (VFIB). In reassessment post-shock, the patient found to be pulseless. Re-analyzed, no shock advised, patient in asystole, CPR resumed. After five minutes, return of spontaneous circulation (ROSC) and sinus rhythm noted on EKG. At this point, the patient had regained consciousness. DIFFERENTIAL DIAGNOSIS: 1. Post-myocardial infarction (MI) scar ventricular arrythmia 2. Recurrent MI 3. Syncope 4. Seizure TESTS AND RESULTS: 1. AED analysis: First Analysis: VFIB, shockable rhythm; Second Analysis: Asystole; no shockable rhythm 2. Post-event 12 Lead EKG: Sinus rhythm, 1st degree AV-block and left bundle branch block, unchanged from prior 3. Post-event Cardiac Catheterization September 9th, 2022: No changes from previous (June 14th 2022) FINAL/WORKING DIAGNOSIS: Post-MI VFIB Arrest; likely related to MI scar TREATMENT AND OUTCOMES: 1. ROSC achieved post-CPR 2. Dual-chamber ICD implanted 3. Patient started on Metoprolol 25 mg once daily 4. Lifting restrictions post-ICD and prior to resuming CR 5. Returned to finish remaining 8 CR sessions, 2 months post-event 6. Post-CR improvements in strength and endurance (46% improvement from entry 6MWT), self-report fatigue symptom score (7/10 at baseline to 0/10 at d/c), and weekly exercise duration (established >180 minutes of moderate-intensity exercise per week).