Skill Checkup: An Electrical Conundrum

Xiaoxiao Qian, MD; Raghav Gattani, MD; Chirag M. Sandesara, MD


June 11, 2021

The Skill Checkup series provides a quick, case-style interactive quiz highlighting key guidelines- and evidence-based information to inform clinical practice.

A 76-year-old man presented with syncope preceded by prolonged dizziness. His medical history was notable for uncontrolled hypertension, gastrointestinal bleeding, carpal tunnel syndrome, stage 3 chronic kidney disease, anemia, and heart failure with preserved ejection fraction (HFpEF). He required multiple hospitalizations in the past 6 months for heart failure exacerbation and intestinal bleeding from gastric arteriovenous malformations and telangiectasias.

On physical examination, the patient's vital signs were normal. He was frail and ill-appearing. Cardiac auscultation revealed a regular rate and rhythm, with no murmur appreciated. Jugular venous distention was present to 10 cm of water. Pulmonary exam demonstrated basilar crackles bilaterally. The abdomen was soft, with flank edema. Extremities were warm, with 2+ pitting edema up to bilateral calves. Skin exam revealed neither lesions nor rash.

Laboratory studies revealed a hemoglobin level of 10.2 g/dL (reference range, 12.5-17.1 g/dL), creatinine level of .5 mg/dL (reference range, 0.7-1.3 mg/dL), troponin level of 0.14 ng/mL (reference range, 0.00-0.05 ng/mL), and N-terminal pro-brain natriuretic peptide (NT-proBNP) level of 11,693 pg/dL (reference range, ≤ 116 pg/dL).

ECG showed first-degree atrioventricular (AV) block (PR, 202 ms), a septal infarction, and low-voltage QRS with a single aberrantly conducted premature atrial complex (Figure 1).

Figure 1. ECG upon presentation. Image courtesy of Xiaoxiao Qian, MD.

Echocardiography demonstrated a moderately decreased left ventricular ejection fraction of 34%; a moderately increased left ventricular septal wall thickness (1.3 cm); and significantly decreased global longitudinal strain (GLS) at -5.5%, with apical sparing (Figure 2).

Figure 2. Top. Echocardiographic parasternal long axis view demonstrating increased left ventricular wall thickness. Bottom. Global longitudinal strain demonstrating apical sparing. Images courtesy of Xiaoxiao Qian, MD.

During the hospital course, multiple runs of nonsustained ventricular tachycardia (VT) were detected on telemetry. The nonsustained VT persisted even after correction of hypokalemia and treatment for heart failure. The patient subsequently had two cardiac arrests due to sustained VT and had return of spontaneous circulation after brief resuscitation with chest compressions and external defibrillation.


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