hsTrop uptrended throughout the night, peaking at 8100. EKGs were repeated, and showed resolution of the ST elevations we saw previously. Instead, there's now diffuse T wave inversions. There were several runs of NSVT overnight, for which cardiology recommended loading with amiodarone. They're not sure if the patient truly had an OMI, though are equally impressed by the hsTrop peak. Regardless, they sign off for now, and ask that we reach back out if LHC becames safe from our perspective. We perform a bedside TTE, which shows moderate inferolateral wall hypokinesis and moderately reduced LV systolic function. The formal TTE corroborates our findings, with a moderately reduced LVEF (40-45%) and estimated RVSP of 35mmHg.
On ICU day 3, she meets criteria for extubation. Unfortunately, reintubation is required six hours later, due to inadequate airway protection. Bronchoscopy identifies subsegmental mucus plugs. hsTrop has downtrended. TCDs are obtained and do not reveal vasospasm.
On ICU day 4, she undergoes a repeat 12-lead EKG as her telemetry monitoring demonstrated concerning findings in the setting of tachycardia. It reveals dynamic inferior ST elevations that resolves with improvements in heart rate control, suggesting demand ischemia. Low-dose metoprolol is initiated, with good effect. Of course, she continues to be carefully monitored, and she never develops signs/symptoms of cardiogenic shock. TCDs demonstrate mild-moderate vasospasm. Neurologically, she remains stable.
Trick question! We don't need to treat this. Sonographic/radiographic vasospasm is common, but doesn't necessarily lead to DCI. In this case, as we know the patient is neurologically stable, we can count this as an isolated imaging finding and avoid treating an imaging study alone.
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