A 67-Year-Old Man With Palpitations and Syncope

Nazem Akoum, MD, MS; Steven A. Lubitz, MD, MPH; Zachary D. Goldberger, MD, MSc, FACC

Disclosures

February 19, 2019

Editorial Collaboration

Medscape &

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 recognize accurately. 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 Case Challenge, please contact us.

Background

A 67-year-old man presents after experiencing palpitations while having dinner with his wife. He describes his heart as "flopping around" in his chest. This sensation lasted for a few minutes and was suddenly followed by lightheadedness and a transient loss of consciousness. His wife reports that he woke up almost right away, within a few seconds. He felt normal afterward. He denies any prodrome and any symptoms of vertigo.

During his interview, he discloses a similar episode about 1 month prior, albeit of milder intensity. That episode was not associated with a loss of consciousness. His past medical history includes hypertension, which is controlled with a diuretic and an angiotensin receptor blocker, and Gilbert disease without significant liver dysfunction. He takes a baby aspirin daily.

He is active, exercises regularly, and works a full-time job. He has not had any symptoms such as chest pain, shortness of breath, or palpitations, presyncope, or syncope associated with exercise. He does not smoke or consume alcohol. He has no known food or drug allergies. His family history includes hypertension on his maternal side without any history of syncope or unexplained sudden death.

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