The Beat Goes On

A CLINICAL PROBLEM-SOLVING article by Kathryn Britton from Brigham and Women's Hospital, Boston.
A 45-year-old man presented at a hospital after having a syncopal event while watching a baseball game. The syncopal event was preceded by the sudden onset of light-headedness. He awoke after several seconds, without confusion. He reported having nausea and diaphoresis but had no chest pain before or after the event. An emergency-medical-services team obtained an electrocardiogram that revealed monomorphic, wide-complex tachycardia at a rate of 240 beats per minute; the blood pressure was 110/50 mm Hg. The team administered amiodarone, without effect. On arrival at the hospital, his systolic pressure was 70 mm Hg. Electrocardioversion was performed, with successful restoration of sinus rhythm. Pertinent electrocardiographic findings noted before cardioversion included QS complexes across the precordium and right-axis deviation. Analysis of these findings and the postcardioversion tracing supported the diagnosis of ventricular tachycardia.
After the patient's condition was stabilized, further history was obtained. The patient reported receiving a diagnosis of cardiomyopathy 6 months earlier. An echocardiogram revealed normal left ventricular wall thickness, an ejection fraction of 40%, and inferior-wall hypokinesis.
In the absence of structural heart disease, monomorphic ventricular tachycardia has a benign prognosis. In contrast, when ventricular tachycardia is coupled with underlying cardiac disease, it is associated with an increased risk of death.
Direct investigation and select treatment for this patient with An Interactive Medical Case at NEJM.org. [Original Article]