Background:
Previous studies have shown the beneficial effects of aerobic exercise to lower the rate of future cerebrocardiovascular events among stroke survivors. However, cardiovascular event during early stage aerobic exercise in stroke patients has been rarely reported. We report a severe cardiovascular event during early aerobic exercise even after exercise stress test.
Case:
A 58years old male who had hypertension visited ER for dysarthria and Rt hemiparesis in 2015/08/22. Brain MRI showed multiple infarction (both pontine, Rt. PCA) and basilar artery dissection. TFCA showed basilar artery with 70% stenosis. He was discharged with only mild dysarthria with anticoagulant in 2015/08/28. After 3 days he was readmitted for spinning sense. Brain MRI showed aggravation of Lt pontine & Rt occipital and newly developed Lt cerebellar small infarction, but TFCA showed no interval change. Aspirin was added to the list of medication. After discharge he had weekly outpatient aerobic exercise program without CPET. We prescribed low intensity exercise that raising resting HR +20 and limiting SBP <140mmHg. However, according to PAT report which monitors his home exercise we found his long lasting high intensity self exercise. In 2015/11/30 symptom limited CPET was performed and the result showed initial BP was 135/91mmHg with adequate increasing of BP and HR. Maximal BP reached 168/87mmHg, but in the 3 stage we stopped the test because Max HR was 173BPM (123% of Max HR) and RER reached 1.25. We estimated that he was over-motivated. Even though resting 2min BP (164/84mmHg) was not properly recovered, still EKG reported no ST change and he did not complaint of any symptom. So we classified him as low risk group and recommended him weekly progressive increasing outpatient exercise program combined with home exercise. But PAT report showed that he was doing higher intensity home exercise (more than 1hour with high intensity) then we recommend. We recommended controlling home exercise as we prescribed. In 2015/12/19 during outpatients exercise program (RHR+20, RPE10), several PVCs and V-tachycardia was detected by EKG. Also BP dropped to 80/40mmHg from 140/80mmHg abruptly without symptom. In 2015/12/24 following CPET, however, showed similar results to previous CPET. 2016/03/08 EKG showed normal sinus rhythm & Echocardiography showed normal LV cavity size and systolic function (LVEF 69%) 2016/03/08 CAG was done to further evaluate the cardiac problem, and it showed pLAD, diffuse ecc 50% LN, dLAD, diffuse irregular 80-90% LN, p-dLCx, diffuse irregular 40% LN (diminutive a) pRCA, focal minimal LN, big PL, diffuse irregular 60-70% LN (small vessel caliber) He was prescribed to stop home exercise with intensive medication worrying the short of circulation of dLCx at the high intensity exercise.
Conclusion:
This case suggests the necessity of including cardiac angiography for initial stroke evaluation before starting early stage aerobic exercise. |
