A 54-year-old man with no history of coronary artery disease was walking his dog when he experienced an unwitnessed episode of syncope. He spontaneously regained consciousness within a few minutes. Bystanders took him to the ER, where he underwent noncontrast CT of the head that showed a subdural hematoma with a questionable, small subarachnoid bleed. A 12-lead electrocardiogram showed anterior T-wave inversions, and his troponin T level was positive at 0.4 \u00b5g\/liter. The patient was admitted to the cardiac intensive care unit.<\/p>\n
A 2-dimensional echocardiogram revealed distal anteroseptal and apical wall-motion abnormalities and a left-ventricular ejection fraction of 40%. Because of the intracranial bleed, he was conservatively managed with a beta-blocker, aspirin, and a statin. He remained hemodynamically stable for the next 48 hours without arrhythmias. A repeat CT of the head showed no progression in the subdural hematoma, and no evidence of intracranial bleeding.<\/p>\n
Questions:<\/b><\/p>\n
1. What would be your next step in managing this patient: cardiac catheterization, coronary CT angiography, evaluation for an implantable cardioverter-defibrillator, or some other alternative?<\/p>\n
2. Why would you choose that management approach?<\/p>\n
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Response:<\/b><\/p>\n
James Fang, MD<\/a><\/p>\n May 29, 2013<\/i><\/p>\n This patient\u2019s story begins with syncope that has yet to be explained. Despite the apparent lack of history of CAD, the documented cardiac dysfunction raises the possibility of cardiac syncope. The syncope may have been secondary to ischemia-mediated ventricular tachycardia (VT) or ventricular fibrillation (VF), given the ECG changes, anteroseptal and apical wall-motion abnormalities, and positive troponin. The larger the ischemic territory, the more likely that ischemia may result in VT\/VF.<\/p>\n The case author also leads one to consider that the syncope may have been an arrhythmic manifestation of a previously unrecognized cardiomyopathy (e.g., reduced LV ejection fraction). However, syncope is an unusual first manifestation of asymptomatic LV dysfunction, particularly if recent in onset.<\/p>\n Alternatively, the unexplained syncope may have led to a traumatic subdural hematoma and then secondary LV dysfunction, as may occur in the context of an acute stroke syndrome or significant stress (e.g., Takotsubo cardiomyopathy). In this case, the \u201csyncope\u201d may have resulted from a mechanical, unwitnessed fall while the patient was walking his dog. A subdural hematoma rarely manifests as syncope and, therefore, is unlikely to have been the initial clinical event.<\/p>\n I favor coronary angiography (which can be done safely without heparin) to evaluate the patient\u2019s coronary anatomy, as long as his neurologic status is stable. It\u2019s critical to ascertain explanations for the LV dysfunction and the syncope. Coronary CT could be considered as an alternative if there is significant concern about performing coronary angiography in the presence of a subdural hematoma. A cardiac MRI can be useful to look for evidence of scar (e.g., chronic cardiomyopathy) or a Takotsubo-like problem (JAMA<\/i> 2011; 306:277<\/a>). Evaluation for an ICD should be deferred until the nature of the heart disease is better delineated.<\/p>\n <\/p>\n Follow-Up:<\/b><\/p>\n