A nonsmoker in her 80s with a history of hypertension, dyslipidemia, and asthma was brought to the emergency department after she was found collapsed in her apartment 2 days following a possible syncopal episode. She denied prior cardiac history, seizures, syncope, presyncope, or falls. She had no diabetes or family medical history of coronary artery disease. She took metoprolol, 25 mg, twice daily for hypertension prior to her fall.
The patient was afebrile with a heart rate of 65 beats per minute (bpm) and recorded blood pressure of 165/144 mm Hg. She had normal findings on cardiac, pulmonary, and neurologic examinations. Initial laboratory data were notable for white blood cell count of 16.2 × 109/L, serum sodium of 148 mmol/L, blood urea nitrogen of 24 mg/dL (to convert to mmol/L, multiply by 0.357), creatinine of 1.04 mg/dL (to convert to µmol/L, multiply by 76.25), creatine kinase of 5962 U/L (reference range, <145 U/L; to convert to µkat/L, multiply by 0.0167), and troponin of 1.95 ng/mL (reference range, <0.04 ng/mL; to convert to µg/L, multiply by 1.0). Initial electrocardiogram (ECG) results showed normal sinus rhythm with no ischemic changes. Skeletal x-ray results were normal. Computed tomography results of the brain and cervical spine were normal. She was treated with intravenous fluids and admitted to a telemetry unit for cardiac rhythm monitoring. Overnight, she had multiple 10- to 20-second runs of a wide-QRS complex rhythm with heart rate in the 50s (Figure).
Muniyappa A, Goldschlager N. Wide Complex Ventricular Rhythm in a Patient After Collapse. JAMA Intern Med. Published online April 03, 2017. doi:10.1001/jamainternmed.2017.0467