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Challenges in Clinical Electrocardiography
July 15, 2019

Arrhythmogenic Syncope in a Soldier First-Responder Reveals Channelopathy—Last Response for the First Responder?

Author Affiliations
  • 1Department of Medicine, Tripler Army Medical Center, Honolulu, Hawaii
  • 2Department of Cardiology, Tripler Army Medical Center, Honolulu, Hawaii
JAMA Intern Med. 2019;179(9):1278-1280. doi:10.1001/jamainternmed.2019.2484

A military nurse in her 20s was working in the intensive care unit when her patient experienced sudden cardiac arrest. While performing chest compressions, the nurse collapsed and was found to be without a pulse, prompting activation of a second code blue. The nurse achieved return of spontaneous circulation in the first round of cardiopulmonary resuscitation and was sent for immediate evaluation. Twelve-lead electrocardiogram (ECG) and basic chemistry panel results were unremarkable (Figure 1). She was diagnosed with vasovagal syncope and the sent home. Concerned, the patient sought further evaluation and follow-up was arranged with cardiology specialists. Further medical history was obtained, which included multiple episodes of unexplained childhood syncope. Subsequent evaluation with cardiac magnetic resonance imaging, transthoracic echocardiogram, and coronary computed tomographic angiogram showed no evidence of congenital disease, valvular disease, anomalous coronary arteries, or chamber dilatation. A graded exercise tolerance test (GXT) was performed to evaluate for exercise-induced arrhythmias; it was observed that at heart rates above 125 bpm, frequent premature ventricular contractions (PVCs) developed in a bigeminy pattern, and in late stage 2 of a Bruce protocol, her ECG results demonstrated nonsustained but bidirectional polymorphic ventricular tachycardia (VT) (Figure 2) that persisted in early stage 3 and subsequently led to termination. In early recovery of the GXT, there was no evidence of VT or PVC, with normal intervals (Figure 3).

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