A Coffee Drinker With Sudden-Onset Dyspnea, Tachycardia

Lemi Luu, MD


April 28, 2022

Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 40-year-old man presents to the emergency department with palpitations and shortness of breath that started a few minutes before his arrival.

The patient states that he was closing his shop when his heart began to beat rapidly and he had difficulty catching his breath. His symptoms started suddenly and continued when paramedics arrived minutes later. They observed a rapid heart rate on the cardiac monitor and associated rhythm strips (Figures 1 and 2). He was subsequently given adenosine 0.6 mg en route to the hospital. The patient had a momentary period of asystole, but his rapid heart rate returned.

Figure 1.

Figure 2.

On his arrival to the emergency department, the patient continued to have the sensation that his heart was racing. He denies having any chest pain, nausea, vomiting, diaphoresis, light-headedness, or recent illness. He felt well before this episode. He denies having any symptoms of infection, such as fever, cough, vomiting, diarrhea, anorexia, or dysuria. He reports increased stress at work and is drinking at least 4 cups of coffee a day. He reports no notable history of medical conditions except for a similar episode of a rapid heart rate about 4 years ago; for this, he was treated with a drug he does not remember for 2 years.

His family history is significant for a father who died of a myocardial infarction at age 45 years. The patient takes 1 baby aspirin daily. He denies using any over-the-counter or illicit drugs; however, he smokes 3 packs of cigarettes per week.


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