Subsequently, a dipyridamole pharmacologic stress test was ordered to rule out ischemic cardiomyopathy. However, the patient was noted to have bouts of non-sustained ventricular tachycardia. No significant arrhythmia occurred spontaneously or with induction protocols during the study, with or without provocation. ![]() There was decremental VA conduction, and no septal accessory pathway (with paraHisian pacing). The study revealed normal sinus node function and AV nodal conduction, decremental AV conduction, no dual AV nodal physiology, no AV nodal echoes, and a normal His-Purkinje system. Later, he underwent electrophysiology (EP) study for possible ablation of atrial tachycardia. Recordings from Holter monitor showing VT. Premature atrial contraction (PAC) and premature ventricular contraction (PVC) burdens were 4.80% and 4.26%, respectively. There were three episodes of ventricular tachycardia (VT), the longest being 15 beats at an average rate of 129 bpm up to 160 bpm (Figure (Figure2). He was diagnosed with heart failure with moderately reduced ejection fraction (HFmrEF) and was started on guideline-directed medical therapy and was followed up in an outpatient cardiology clinic.ĭuring his outpatient visit, the patient was given a Holter monitor to rule out arrhythmias which revealed a predominant rhythm of NSR and 66 episodes of atrial tachycardia (AT), the longest being 20 beats at an average rate of 153 bpm (Figure (Figure1). There was mild diffuse LV hypokinesis with mild tricuspid regurgitation (TR). On his first admission for a syncopal episode, a transthoracic echocardiogram (TTE) was performed which was significant for left ventricular (LV) ejection fraction (LVEF) of 40-45%. EKG revealed normal sinus rhythm (NSR) at 85 beats per minute with isolated premature ventricular contractions (PVC) and a QTc of 423. His laboratory values are shown in Table Table1. Chest 1. Chest x-ray was negative for any acute pathology. Orthostatic vitals remained negative and physical exams were unremarkable. His vitals were notable only for hypertension with systolic blood pressure ~140 s and diastolic of ~80 s. The patient had multiple visits to the emergency department (ED) including two hospital admissions for syncopal events. His medications included amlodipine 5 mg daily, Ferrous sulfate 350 mg daily, docusate calcium 240 mg daily, omeprazole 20 mg daily, and tamsulosin 0.4 mg daily. His baseline hemoglobin was 8.8 g/dL nevertheless, his recent colonoscopy last year was unremarkable. Additionally, he denied any headache, nausea, vomiting, chest pain, or shortness of breath during these episodes. He admitted experiencing pre-syncopal and syncopal events for two months which began with a sudden sensation of lightheadedness associated with diaphoresis subsequently, he was minimally or completely unresponsive witnessed by his wife, lasting 10-15 s, without any convulsive behavior, post-ictal state, or loss of bowel or urinary continence. Our patient is an 81-year-old male with a past medical history of hypertension, benign prostatic hyperplasia (BPH), and iron deficiency anemia attributed to chronic hemorrhoids. This rare presentation serves as a reminder to consider ischemic heart disease in the evaluation of syncope. Extensive transmural ischemia could lead to ventricular arrhythmias, a known cause of syncope. It is very rare for ischemic cardiomyopathy to present as syncope however, it is not unheard of. The patient was successfully discharged with guideline-directed medical therapy for heart failure with reduced ejection fraction (HFrEF) and coronary artery disease (CAD). The patient underwent a coronary artery bypass graft (CABG) with subsequent resolution of further syncopal events. The workup revealed ischemic ventricular tachycardia in the setting of significant coronary artery disease including 80% distal left main disease. Differentials to consider during the workup of syncope includes vasovagal, orthostatic, drug-induced, arrhythmia, structural heart disease, and ischemic cardiomyopathy.Īn 81-year-old African American man with recurrent witnessed syncopal events and newly diagnosed heart failure underwent extensive cardiac workup including electrocardiograms (EKG), echocardiogram, Holter monitor, electrophysiology (EP) study, and coronary angiogram. ![]() Syncope is usually caused by cerebral hypoperfusion.
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