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Rhythm Disorders

Wide Complex QRS During Sotalol Administration

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

1 Credit CME

JAMA Cardiology

Published Online: January 26, 2022

JAMA Cardiology Clinical Challenge

Article Information and Disclosures

Albert J. Rogers, MD, MBA^1,2;

Paul J. Wang, MD^1,2;

Nitish Badhwar, MD^1,2

Author Affiliations

¹Department of Medicine, Stanford University, Stanford, California
²Cardiovascular Institute, Stanford University, Stanford, California

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A man in his 40s was seen in clinic for a long history of palpitations. He had a history of cardiac arrest after receiving adenosine for sustained supraventricular tachycardia and tachycardia-induced cardiomyopathy. The patient was also noted to have episodes of atrial flutter. Transthoracic echocardiogram displayed a left ventricular ejection fraction of 63% and mild aortic and mitral regurgitation. Cardiac magnetic resonance imaging in sinus rhythm showed mild left ventricle thickening (up to 14 mm) and was otherwise normal. The patient was hospitalized for initiation of sotalol, given that he experienced frequent episodes of atrial arrhythmia. Figure 1A shows sinus rhythm prior to sotalol initiation. Figure 1B shows telemetry during administration of sotalol.

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A man in his 40s was seen in clinic for a long history of palpitations. He had a history of cardiac arrest after receiving adenosine for sustained supraventricular tachycardia and tachycardia-induced cardiomyopathy. The patient was also noted to have episodes of atrial flutter. Transthoracic echocardiogram displayed a left ventricular ejection fraction of 63% and mild aortic and mitral regurgitation. Cardiac magnetic resonance imaging in sinus rhythm showed mild left ventricle thickening (up to 14 mm) and was otherwise normal. The patient was hospitalized for initiation of sotalol, given that he experienced frequent episodes of atrial arrhythmia. Figure 1A shows sinus rhythm prior to sotalol initiation. Figure 1B shows telemetry during administration of sotalol.

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Article Information

Corresponding Author: Albert J. Rogers, MD, MBA, Department of Medicine, Stanford University, 780 Welch Rd, MC 5773, Stanford, CA 94305 (rogersaj@stanford.edu).

Published Online: January 26, 2022. doi:10.1001/jamacardio.2021.5788

Conflict of Interest Disclosures: None reported.

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

References

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Robinson K , Rowland E , Krikler DM . Latent pre-excitation: exposure of anterograde accessory pathway conduction during atrial fibrillation. Br Heart J. 1988;59(1):53-55. doi:10.1136/hrt.59.1.53 PubMed Google Scholar Crossref

Krikler DM , Goodwin JF . Cardiac Arrhythmias: The Modern Electrophysiological Approach. WB Saunders; 1975:144-161.

Daubert C , Mabo P , Gras D , Leclercq C . Clinical role of d-sotalol and d,l-sotalol in supraventricular arrhythmias, including pre-excitation. Eur Heart J. 1993;14(suppl H):67-73. doi:10.1093/eurheartj/14.suppl_H.67 PubMed Google Scholar Crossref

Touboul P , Atallah G , Kirkorian G , Lavaud P , Mathieu MP , Dellinger A . Effects of intravenous sotalol in patients with atrioventricular accessory pathways. Am Heart J. 1987;114(3):545-550. doi:10.1016/0002-8703(87)90751-4 PubMed Google Scholar Crossref

Fitzpatrick AP , Gonzales RP , Lesh MD , Modin GW , Lee RJ , Scheinman MM . New algorithm for the localization of accessory atrioventricular connections using a baseline electrocardiogram. J Am Coll Cardiol. 1994;23(1):107-116. doi:10.1016/0735-1097(94)90508-8 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.