An Unusual Case of Cardiac Arrest
A 67-year-old man is transferred to our institution from an outside facility after suffering a witnessed cardiac arrest at home. He has a medical history of hypertension, dyslipidemia, coronary atherosclerosis, prior inferior non-ST-segment elevation myocardial infarction, and sick sinus syndrome post dual-chamber pacemaker implantation.
The patient initially reported sudden onset of chest pain described as "a brick on my chest" and collapsed a few minutes later. He was resuscitated promptly by his son. Upon arrival of emergency medical services, he was found to be in ventricular fibrillation. A 200 J asynchronous shock was delivered, after which he developed pulseless electrical activity. Return of spontaneous circulation was achieved after a total of 28 minutes of appropriate cardiopulmonary resuscitation. The patient arrived comatose at an outside facility approximately 35-40 minutes after losing consciousness. An electrocardiogram was obtained and is shown in Figure 1. His laboratory results were consistent with mild lactic acidosis (lactic acid = 3.6 mmol/L), normal renal function, and a cardiac troponin I level of 0.035 ng/mL. A limited transthoracic echocardiogram showed no significant wall motion abnormalities, no significant valvular lesion, and a new small pericardial effusion. The patient was emergently transferred to the cardiac catheterization laboratory at our hospital. Coronary angiograms of his left and right coronary artery are shown in Videos 1 and 2, respectively.
Based on the clinical history and diagnostic tests described, what would be the next best step in the management of this patient?