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Wide Complex Tachycardia in a Woman in Her 30s With Electrolyte Derangements

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A woman in her 30s with active bulimia was brought by ambulance to the emergency department after a syncopal event that followed 1 hour of palpitations and intermittent lightheadedness. When emergency responders arrived, the patient was responsive but groggy. An electrocardiogram (ECG) in the field demonstrated a regular wide complex tachycardia. En route to the hospital, 6 mg of adenosine followed by 12 mg of adenosine were administered intravenously, without a change in her rhythm.

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Arrhythmogenic right ventricular cardiomyopathy

C. Cardiac magnetic resonance imaging

The initial and postcardioversion ECGs raise suspicion for an underlying structural abnormality, and further characterization with additional imaging is recommended. The initial ECG (Figure, A) shows a regular wide complex tachycardia with a rate of 225 beats per minute. The inferior axis and left bundle-branch block pattern in the precordial leads with late transition (V5) are consistent with ventricular tachycardia (VT) originating in the right ventricular outflow tract. Once the rhythm was determined to be VT, the initial differential diagnosis for this relatively young woman with electrolyte abnormalities, no cardiac history, and no family history of sudden cardiac death included both structural and nonstructural processes.

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Article Information

Corresponding Author: Paul J. Marano, MD, University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143 (paul.marano@ucsf.edu).

Published Online: December 26, 2019. doi:10.1001/jamacardio.2019.4838

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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Corrado  D, Link  MS, Calkins  H.  Arrhythmogenic right ventricular cardiomyopathy.  N Engl J Med. 2017;376(15):1489-1490. doi:10.1056/NEJMc1701400PubMedGoogle ScholarCrossref
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Kaplan  SR, Gard  JJ, Protonotarios  N,  et al.  Remodeling of myocyte gap junctions in arrhythmogenic right ventricular cardiomyopathy due to a deletion in plakoglobin (Naxos disease).  Heart Rhythm. 2004;1(1):3-11. doi:10.1016/j.hrthm.2004.01.001PubMedGoogle ScholarCrossref
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