Due to the increased use of internal mammary artery grafts for coronary revascularization, proximal subclavian stenosis resulting in coronary-subclavian steal has become an important clinical entity. Patients present with varying signs and symptoms of recurrent myocardial ischemia that not only can limit lifestyle but also be life-threatening. A careful history and physical examination with the identification of risk factors such as peripheral vascular disease and arm blood pressure differential >20 mm Hg can identify patents at high risk for developing this syndrome. Identifying these patients before coronary artery bypass grafting can prevent this important problem by altering the therapeutic approach to coronary revascularization. When patients present after coronary artery bypass grafting with coronary-subclavian steal, therapeutic options of percutaneous transluminal angioplasty and stent placement to the subclavian artery, carotid-subclavian bypass, and axillary-axillary bypass all have high success rates with excellent long-term patency rates. The choice for the type of revascularization needs to be individualized based on the lesion morphology and clinical comorbidities. Three patients who presented with signs and symptoms of myocardial ischemia due to coronary subclavian steal are presented. All 3 patients had incapacitating symptoms, and all 3 were treated successfully with different revascularization techniques due to other medical conditions or comorbidities.

1 Survival to hospital admission or discharge is dismal: less than 30% of patients survived to hospital admission and less than 10% survived to discharge, according to data from the Cardiac Arrest Registry (CARE).2 Survival to discharge is driven mainly by neurologic injury, which accounted for two thirds of OHCA deaths in one study.3 Two studies from 2002 4,5 reported significant improvements in the rates of neurologic recovery and subsequent survival following the induction of mild hypothermia in patients who remained comatose upon resuscitation. However, a more recent and larger study suggests that targeted temperature management, rather than the induction of hypothermia, is the fundamental element for neurologic recovery. 6As of 2013, there were 2 reported cases of pregnant patients who underwent therapeutic hypothermia (TH) with a favorable outcome for both mother and fetus.7,8 A 3rd case study reported mixed results, with fetal demise balanced by the survival of the mother after prolonged hospitalization. 9 We report the use of TH in a pregnant patient, with favorable recovery for both mother and fetus. Our case, along with the other published cases, highlights the fact that pregnancy should not be considered an absolute contraindication for TH. Case ReportA 20-year-old previously healthy black woman, 18 weeks pregnant, experienced OHCA while running on a treadmill at a gymnasium. She was down for approximately 5 minutes before cardiopulmonary resuscitation (CPR) was begun upon EMS arrival. The initial rhythm check revealed that the patient was in ventricular fibrillation cardiac arrest. She promptly received 2 defibrillator shocks and experienced return of spontaneous circulation (ROSC) after approximately 8 minutes of resuscitation.

Flecainide is recommended as a first-line antiarrhythmic drug to maintain normal sinus rhythm in patients with atrial fibrillation (AF) who have structurally normal hearts or hypertension without left ventricular hypertrophy. Flecainide is a sodium channel blocker with minimal effects expected on ventricular repolarization. We describe the case of a 32-year-old man with a structurally normal heart and persistent AF who was started on diltiazem and flecainide 50 mg twice/day approximately a year prior to presentation. Due to persistent and bothersome symptoms, his dose was increased to 150 mg twice/day, which was associated with a progressive lengthening of his corrected QT interval. On the day of presentation, he underwent an exercise test as part of his job requirements. While running, he felt lightheaded and experienced a syncopal event and cardiac arrest. An automated external defibrillator was available that displayed polymorphic ventricular tachycardia. The patient was successfully resuscitated. Although rare, this case suggests that flecainide can induce QT prolongation leading to torsades de pointes. Clinicians should be aware and consider periodic evaluations with electrocardiograms.

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