A Patient with Syncope

A CLINICAL PROBLEM-SOLVING article by Michelle Fox from Brigham and Women's Hospital, Boston.
A 35-year-old man presented to the emergency department after having an episode of syncope while playing soccer. Loss of consciousness which lasted only seconds was preceded by a brief period of light-headedness. The patient reported no nausea, diaphoresis, chest pain, or dyspnea. He did not take medications. Witnesses reported no tonic–clonic movements.
He was born in Mexico, immigrated to the United States as a teenager, and lived with his wife in western Massachusetts, where he worked as a dairy farmer.
At initial presentation, the patient had normal vital signs, and the physical examination was unremarkable. The patient was discharged with an event monitor. 2 weeks later he had an episode of monomorphic wide-complex tachycardia, with a heart rate of almost 300 beats per minute, while playing soccer. At the time, he noted mild dyspnea and neck discomfort. He was admitted for further evaluation and management of his condition.
At the time of this patient's initial presentation, idiopathic ventricular tachycardia was the most likely diagnosis. However, the clinical features of recurrent arrhythmia and the patient's region of origin argued for a more complicated process. It is essential in such cases to perform a reassessment for the presence of structural heart disease, which can evolve over time.