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Unexpected Cause Behind Life-threatening ECG Changes—A Diagnostic Challenge

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

A patient in their 60s presented to the hospital with sudden loss of consciousness and foaming at the mouth. The patient had no history of arrhythmias. There was no family history of sudden unexpected death or fatal cerebrovascular accident. The patient’s temperature was 36 °C, heart rate was 124 beats/min, and blood pressure was 55/32 mm Hg. Pulse oximetry showed arterial oxygen saturation of 99% on room air. Both pupils were 3 mm in diameter and reactive to light. The patient’s skin was cool, moist, and cyanosed. Lung fields were clear and heart sounds could not be distinguished due to tachycardia. The initial serum troponin T level was 6.06 ng/mL (to convert to µg/L, multiply by 1; normal range, ≤0.02 ng/mL), brain-type natriuretic peptide was 2542 pg/mL (to convert to ng/L, multiply by 1; normal range, <400 pg/mL), and D-dimer was 0.51 µg/mL (to convert to nmol/L, multiply by 5.476; normal range, 0-0.55 µg/mL). The patient’s electrocardiogram (ECG) on admission is shown in the Figure, A.

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Fuzi, a commonly used traditional Chinese medicine, contains aconitine. Moreover, excessive aconitine intake has cardiotoxic and neurotoxic effects.

Bidirectional ventricular tachycardia is a rare, regular ventricular tachyarrhythmia with 2 distinct QRS morphologies, alternating beat-to-beat.1 During BVT, the surface ECG most often shows tachycardia, and right bundle-branch block (RBBB) morphology and alternating QRS axis are most evident in the inferior limb leads. In addition, there have been cases of BVT with left bundle-branch block (LBBB) and alternating LBBB and RBBB morphologies. Bidirectional ventricular tachycardia has been associated with digoxin toxicity and aconitine poisoning. It can also occur in patients with myocardial ischemia and catecholaminergic polymorphic ventricular tachycardia (CPVT).

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Article Information

Corresponding Author: Xiao-Ce Dai, MD, PhD, Department of Cardiology, Affiliated Hospital of Jiaxing University, No. 1882 Zhong huan Road, Jiaxing, China; 314000 (ielts_kris@163.com).

Published Online: November 14, 2022. doi:10.1001/jamainternmed.2022.4777

Conflict of Interest Disclosures: None reported.

References
1.
Grimard  C , De Labriolle  A , Charbonnier  B , Babuty  D .  Bidirectional ventricular tachycardia resulting from digoxin toxicity.   J Cardiovasc Electrophysiol. 2005;16(7):807-808. doi:10.1111/j.1540-8167.2005.40776.xPubMedGoogle ScholarCrossref
2.
Tai  YT , Lau  CP , But  PP , Fong  PC , Li  JP .  Bidirectional tachycardia induced by herbal aconite poisoning.   Pacing Clin Electrophysiol. 1992;15(5):831-839. doi:10.1111/j.1540-8159.1992.tb06849.xPubMedGoogle ScholarCrossref
3.
Baher  AA , Uy  M , Xie  F , Garfinkel  A , Qu  Z , Weiss  JN .  Bidirectional ventricular tachycardia: ping pong in the His-Purkinje system.   Heart Rhythm. 2011;8(4):599-605. doi:10.1016/j.hrthm.2010.11.038PubMedGoogle ScholarCrossref
4.
Laitinen  PJ , Brown  KM , Piippo  K ,  et al.  Mutations of the cardiac ryanodine receptor (RyR2) gene in familial polymorphic ventricular tachycardia.   Circulation. 2001;103(4):485-490. doi:10.1161/01.CIR.103.4.485PubMedGoogle ScholarCrossref
5.
Tatli  E , Aktoz  M , Barutcu  A , Altun  A .  Bidirectional tachycardia in a patient with pulmonary embolism.   Cardiol J. 2010;17(2):194-195.PubMedGoogle Scholar
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