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Tachycardiomyopathy—The Eye Cannot See What the Mind Does Not Know

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A patient in his 20s presented with recurrent palpitations and progressive heart failure for 6 months. He reported no comorbidities. Physical examination revealed a pulse rate of 120 beats per minute (bpm) and blood pressure of 100/60 mm Hg. The rest of his cardiovascular examination was otherwise unremarkable. Transthoracic echocardiography demonstrated global hypokinesia and moderate left ventricular dysfunction, with an ejection fraction (EF) of 35% to 40% and normal valve function. He was prescribed furosemide, spironolactone, ramipril, and metoprolol succinate. A week later, the patient complained of palpitations despite maximally tolerated β-blocker dose. The patient underwent a 12-lead electrocardiogram (ECG) (Figure, A).

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Tachycardiomyopathy comes under the umbrella of arrhythmia-induced cardiomyopathy, which includes AF-induced and premature ventricular contractions–induced cardiomyopathy as well. Tachycardiomyopathy refers to left ventricular (LV) dysfunction secondary to an increase in ventricular rate, regardless of the origin of the tachycardia. Risk depends not only on the type of tachycarda but also on the rate as well as the duration of tachycardia.2

There are several causes of T-CM, the most common being AF and atrial flutter with rapid ventricular rates, although rarer but very important causes are persistent or incessant AT, sustained sinus tachycardias, ventricular tachycardias, and pacemaker-mediated tachycardias. Atrioventricular reentrant tachycardia (AVRT), and atypical atrioventricular nodal reentrant tachycardia (AVNRT) are usually paroxysmal and therefore are rare causes of T-CM. A high index of suspicion in patients with systolic heart failure or heart failure with reduced ejection fraction is required, and strong consideration of T-CM should be made when patients present with a persistent heart rate above 100 bpm with heart failure. Historically, heart failure and cardiomyopathy are associated with arrhythmias, so it is easy to overlook rhythms like sinus tachycardia if it is not a characteristic of other supraventricular tachycardias (SVTs). The primary step in identifying atrial tachycardias begins with a detailed examination of the surface electrocardiographic findings.3

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Article Information

Corresponding Author: Anunay Gupta, MD, DM, Department of Cardiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi-110029 (dranunaygupta@gmail.com).

Published Online: March 28, 2022. doi:10.1001/jamainternmed.2022.0515

Conflict of Interest Disclosures: None reported.

References
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Huizar  JF , Ellenbogen  KA , Tan  AY , Kaszala  K .  Arrhythmia-induced cardiomyopathy: JACC state-of-the-art review.   J Am Coll Cardiol. 2019;73(18):2328-2344. doi:10.1016/j.jacc.2019.02.045PubMedGoogle ScholarCrossref
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