A 67-Year-Old Man With Palpitations and Syncope

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

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February 19, 2019

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Physical Examination and Workup

Physical examination in the office revealed a healthy-appearing man in no distress. His vital signs were normal. His physical examination findings were also normal, including a thorough cardiovascular evaluation that revealed no abnormal heart sounds including murmurs, rubs, or gallops. He had normal carotid pulses, as well as in his upper and lower extremities. An ECG revealed normal sinus rhythm with normal conduction intervals, with no evidence of ischemia and no signs of a prior myocardial infarction. An echocardiogram showed mild left ventricular hypertrophy and normal biventricular function, normal valve function, mild atrial enlargement, and Doppler evidence of impaired ventricular relaxation. Complete blood count and comprehensive chemistry panel findings were normal, except for mildly elevated bilirubin. His thyroid-stimulating-hormone level was normal.

Ambulatory cardiac monitoring with a 30-day event monitor revealed electrocardiograms such as the one shown in the figure below, followed by resumption of sinus rhythm associated with symptoms of dizziness.

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