A female patient in her 20s presented to our medical centre with a 4-month history of recurrent attacks of transient loss of consciousness that were essentially related to severe emotional situations. These attacks were previously attributed to a reflex syncope after performing routine investigations that comprised a complete blood count, a resting 12-lead surface ECG, echocardiography, and an electroencephalogram that showed normal results. However, she was recently advised to consult a tertiary health care centre because her episodes have become more frequent recently. The patient has a nonsignificant past medical history, and she reported no positive family history of similar condition to the best of her knowledge.
During hospital admission, she suffered an exercise-related presyncope while performing a stress ECG at a heart rate of 120–130 b.p.m. (1st Bruce stage). As shown in Figure 1, the ECG transformed from a regular sinus rhythm into a bidirectional ventricular tachyarrhythmia (alternating 180°-QRS axis on a beat-to-beat basis) which is a characteristic pattern of catecholaminergic polymorphic ventricular tachycardia.1 The ECG demonstrated progressive ventricular ectopy as the heart rate increased during exercise, followed by bidirectional ventricular tachycardia.
Figure 1.
Transition from a regular sinus rhythm into a bidirectional ventricular tachyarrhythmia comprising an alternating 180°-QRS axis on a beat-to-beat basis.
Catecholaminergic polymorphic ventricular tachycardia is a potentially lethal, inherited arrhythmogenic disease characterized by cardiac electrical instability exacerbated by acute activation of the adrenergic nervous system.2 Therefore, the patient was indicated for: (i) genetic testing (Andersen–Tawil syndrome or long-QT syndrome is differential diagnosis), (ii) implantable cardioverter-defibrillator as primary prevention of sudden cardiac death, and (iii) long-term treatment with non-selective beta-blockers such as nadolol to decrease the frequency of shocks delivered by the device.3
Diagnosis of benign reflex syncope is usually gender-biased towards young female patients, and this bias can mask potentially life-threatening arrhythmogenic diseases in otherwise structurally normal hearts. Therefore, rigorous clinical evaluation and ancillary tests may be needed to confirm the diagnosis.
Consent: Appropriate consent was taken from the patient to publish this article in compliance with the COPE guidelines.
Funding: The authors state that this article received no funding.
Contributor Information
Eslam Abbas, Department of Cardiology, Arab Contractors Medical Centre (ACMC), Cairo 11765, Egypt.
Kareem Abdelshafi, Department of Cardiology, Arab Contractors Medical Centre (ACMC), Cairo 11765, Egypt.
Data availability
All datasets underlying this article are available are presented in the main paper.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All datasets underlying this article are available are presented in the main paper.