A patient in their late 50s presented to the emergency department for acute onset chest pain with diaphoresis. The patient reported having had chest tightness followed by mild dyspnea after rushing down a set of stairs 2 days prior. The pain had gradually subsided after resting. In addition, on the evening of admission, just after finishing a meal, the patient experienced a fairly sudden onset of severe nonradiating pressure-like pain in the central portion of the chest accompanied by cold sweating; the pain persisted and progressed. Self-reported medical history included smoking 1 pack of cigarettes daily for more than 3 decades and taking medications for type 2 diabetes and hypertension.
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An ECG with alternating QRS complex morphologic findings has numerous potential causes and invokes an electrocardiographic differential diagnosis including but not limited to ventricular bigeminy, electrical alternans, atrial bigeminy with aberrant conduction, bidirectional ventricular tachycardia, sinus rhythm with alternating bundle-branch block, and WPW alternans. Electrical alternans are classically associated with substantial pericardial effusion with or without cardiac tamponade. True electrical alternans should draw early and aggressive investigation and correlation with the physical examination findings. In this case, alternating QRS complexes of differing amplitude were observed but the width of the QRS complexes and the PR intervals varied from beat to beat, which would not be expected with electrical alternans.
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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.
Corresponding Author: Po-Chih Lin, MD, Cardiovascular Center, Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, No. 7 Zhongshan S Rd, Zhongzheng, Taipei 100, Taiwan (firstname.lastname@example.org).
Published Online: September 26, 2022. doi:10.1001/jamainternmed.2022.3965
Conflict of Interest Disclosures: None reported.
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