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Bizarre Wide-Complex Tachycardia in a Man in His 60s With Severe Chest Pain

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To identify the key insights or developments described in this article
1 Credit CME

A man in his 60s presented to the emergency department with chest pain of 18-hour duration. On admission, his pulse was 129 beats per minute, respiratory rate was 36 breaths per minute, and blood pressure was 126/77 mm Hg. An electrocardiogram (ECG) showed a regular wide-complex tachycardia, which raised concern about ventricular tachycardia (Figure, A). We identified a 1:1 atrioventricular relationship in leads V4-5 but did not exclude ventricular tachycardia with 1:1 retrograde conduction.1 Rather than wide QRS complexes, the ECG tracing suggested a combination of QRS and extreme ST-deviation (Figure, B). The triangular or lambda-shaped QRS-ST ECG pattern appears to be an ominous sign with a malignant prognosis in patients with acute ST-elevation myocardial infarction.2,3 Emergent coronary arteriography showed a thrombotic completely occluded left anterior descending artery, which was effectively revascularized percutaneously. However, because the coronary artery thrombosis was complicated by polymorphic ventricular tachyarrhythmia and cardiogenic shock, the patient eventually required extracorporeal membrane oxygenation support. Unfortunately, the patient’s health status continued to deteriorate, and he died 1 day later.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Chin-Feng Tsai, MD, PhD, Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital, School of Medicine, Chung Shan Medical University, No. 110, Sec. 1, Jianguo N. Road, Taichung City 40201, Taiwan (alberttsai54@hotmail.com).

Conflict of Interest Disclosures: Dr Tsai reported receiving a grant from Chung Shan Medical University Hospital outside the submitted work. No other disclosures were reported.

Reference
1.
Wellens  HJ , Bär  FW , Lie  KI .  The value of the electrocardiogram in the differential diagnosis of a tachycardia with a widened QRS complex.   Am J Med. 1978;64(1):27-33. doi:10.1016/0002-9343(78)90176-6Google ScholarCrossref
2.
Aizawa  Y , Jastrzebski  M , Ozawa  T ,  et al.  Characteristics of electrocardiographic repolarization in acute myocardial infarction complicated by ventricular fibrillation.   J Electrocardiol. 2012;45(3):252-259. doi:10.1016/j.jelectrocard.2011.11.007PubMedGoogle ScholarCrossref
3.
Gussak  I , Bjerregaard  P , Kostis  J .  Electrocardiographic “lambda” wave and primary idiopathic cardiac asystole: a new clinical syndrome?   J Electrocardiol. 2004;37(2):105-107. doi:10.1016/j.jelectrocard.2004.01.001PubMedGoogle ScholarCrossref
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