High-Risk Percutaneous Coronary Intervention in the Era of Public Reporting
Clinical and Ethical Considerations in the Care of an Elderly Patient With Critical Left Main Disease and Shock
A 73-year-old white woman presented to a community hospital emergency department with 7 days of productive cough, dyspnea, and fatigue. Her vital signs were as follows: temperature, 99.9°F; pulse, 100 bpm; respiratory rate, 16 breaths per minute; blood pressure, 153/78 mm Hg; and oxygen saturation, 97% on room air. Her jugular venous pressure was normal; her lungs were clear; and her cardiac examination demonstrated tachycardia but no murmurs or gallops. Extremities were warm without edema. Her complete blood count was normal with the exception of a mild leukocytosis (13 000 cells/mm3). Her electrolytes and renal function were normal (creatinine, 0.8 mg/dL). Her troponin T level was <0.01 ng/mL. A chest radiograph demonstrated a subtle right middle lobe infiltrate. Intravenous ceftriaxone and azithromycin were given for community-acquired pneumonia.
Relevant medical history included hypertension, hyperlipidemia, and an ischemic stroke 21 months previously that resulted in residual right hemiplegia. She had no history of cardiac disease. The patient was married and lived at home with her husband, who assisted her with many of her activities of daily living.
While in the emergency department, the patient became unresponsive, and ventricular fibrillation was detected on the telemetry monitor. Cardiopulmonary resuscitation was delivered for 3 minutes, and sinus rhythm was restored after 1 defibrillatory shock. The patient was subsequently intubated for airway protection and loaded with intravenous amiodarone, and an ECG was obtained (Figure 1). Hypotension ensued over the next 10 minutes, and dopamine was initiated for hemodynamic support. Requests were made to transfer the patient to a tertiary care facility with 24-hour cardiac catheterization capability.
Dr Yeh: The patient’s initial …