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[ST trend analysis. Monitoring of risk patients?]
H J Rapp1, P Gasteiger, K von Ackern
1Institut für Anästhesiologie und Operative Intensivmedizin, Klinikum der Stadt Mannheim, Medizinische Fakultät, Universität Heidelberg.
Insights
Continuous ST-segment monitoring effectively detects silent myocardial ischemia during surgery. This case highlights its importance in preventing perioperative cardiac events, even without chest pain.
Area of Science:
- Cardiology
- Perioperative Medicine
- Intensive Care
Background:
- Silent myocardial ischemia is a significant risk factor for perioperative cardiac morbidity.
- ST-segment monitoring is a valuable tool for detecting myocardial ischemia.
Observation:
- A 72-year-old patient with peripheral vascular disease experienced severe, asymptomatic ST-segment deviations during and after iliaco-femoral bypass surgery.
- Postoperative ST-segment deviation and arrhythmias led to cardiac failure and pulmonary edema.
- Inadequate recognition of ECG changes and elevated heart rate in the recovery phase contributed to delayed intervention.
Findings:
- Perioperative ST-segment monitoring revealed significant silent myocardial ischemia.
- The patient's lack of anginal symptoms masked the severity of the ischemic episodes.
- Delayed recognition of ECG changes and elevated heart rate preceded a major cardiac event.
Implications:
- This case underscores the critical role of continuous ST-segment monitoring in identifying silent myocardial ischemia in high-risk surgical patients.
- Early detection of silent ischemia through ST-segment monitoring can enable timely intervention, potentially preventing severe cardiac complications.
- Enhanced vigilance for ECG changes, even in the absence of symptoms, is crucial for optimizing perioperative cardiac care.
Abstract:
ST-segment monitoring has been proved to be an effective tool in detecting silent myocardial ischaemia, which is an important factor for perioperative cardiac morbidity. The case of a 72-year-old patient with peripheral vascular disease who underwent iliaco-femoral bypass surgery due to acute occlusion of a existing femoropopliteal bypass is reported. As part of a study the patient had perioperative ST-segment holter monitoring which showed pre-, peri- and postoperative severe episodes of silent myocardial ischaemia. No episode was accompanied by anginal symptoms. Post-operatively, a long-lasting episode of severe ST-segment deviation with complex arrhythmias occurred, resulting in cardiac failure and lung oedema. This ST-segment deviation began when the surgical procedure had been concluded and the patient extubated. The peak of the deviation occurred during transport from the operating room the recovery room. The existing ECG changes and the raised heart rate, from the beginning of the time in the recovery room to arrival on the normal ward, were not adequately recognized. The lack of clinical symptoms was misinterpreted. Many hours before, ST deviations and higher heart rate could be seen as precursors of a severe cardiac event. This demonstrates the importance of silent ischaemia in the perioperative period and shows the usefulness of ECG monitoring, especially of the ST segment, in detecting silent ischaemia and enabling early treatment.