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One Beat Is All It Takes—Wide Complex Tachycardia in a Middle-aged Man

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

A man in his mid-50s with a medical history of nonspecific T-wave abnormalities on electrocardiogram (ECG) reported new-onset chest discomfort, diaphoresis, and shortness of breath that woke him from sleep. Emergency medical services found him to be in a wide complex tachycardia. He was administered a 150-mg bolus of intravenous amiodarone, which failed to terminate his arrhythmia. He ultimately required synchronized cardioversion with a biphasic direct current shock of 100 J. On arrival to the emergency department, his vital signs were stable. Serum electrolyte levels were within normal range and C-reactive protein was less than 6 mg/dL (to convert to milligrams per liter, multiply by 10). High-sensitivity troponin peaked at 1078 pg/mL. His initial 12-lead ECG is shown in Figure 1A. He continued in sinus rhythm with episodes of nonsustained ventricular tachycardia observed on telemetry, as shown in Figure 1B. Cardiac catheterization revealed patent coronary arteries. Cardiac magnetic resonance imaging was remarkable for a dilated right ventricle with moderately reduced systolic function and transmural late gadolinium enhancement with akinesis and dyskinesis involving the right ventricular (RV) free wall and outflow tract extending to the left ventricular (LV) anterior, septal, and apical segments.

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A man in his mid-50s with a medical history of nonspecific T-wave abnormalities on electrocardiogram (ECG) reported new-onset chest discomfort, diaphoresis, and shortness of breath that woke him from sleep. Emergency medical services found him to be in a wide complex tachycardia. He was administered a 150-mg bolus of intravenous amiodarone, which failed to terminate his arrhythmia. He ultimately required synchronized cardioversion with a biphasic direct current shock of 100 J. On arrival to the emergency department, his vital signs were stable. Serum electrolyte levels were within normal range and C-reactive protein was less than 6 mg/dL (to convert to milligrams per liter, multiply by 10). High-sensitivity troponin peaked at 1078 pg/mL. His initial 12-lead ECG is shown in Figure 1A. He continued in sinus rhythm with episodes of nonsustained ventricular tachycardia observed on telemetry, as shown in Figure 1B. Cardiac catheterization revealed patent coronary arteries. Cardiac magnetic resonance imaging was remarkable for a dilated right ventricle with moderately reduced systolic function and transmural late gadolinium enhancement with akinesis and dyskinesis involving the right ventricular (RV) free wall and outflow tract extending to the left ventricular (LV) anterior, septal, and apical segments.

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Article Information

Corresponding Author: Gan-Xin Yan, MD, PhD, Lankenau Medical Center, Main Line Health, 100 Lancaster Ave, Wynnewood, PA 19096 (yang@mlhs.org).

Published Online: January 4, 2023. doi:10.1001/jamacardio.2022.4888

Conflict of Interest Disclosures: Dr Yan is supported by grants from the Sharpe-Strumia Research Foundation. No other disclosures were reported.

References
1.
Marcus  FI , McKenna  WJ , Sherrill  D ,  et al.  Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia: proposed modification of the task force criteria.   Circulation. 2010;121(13):1533-1541. doi:10.1161/CIRCULATIONAHA.108.840827PubMedGoogle ScholarCrossref
2.
Corrado  D , Basso  C , Thiene  G ,  et al.  Spectrum of clinicopathologic manifestations of arrhythmogenic right ventricular cardiomyopathy/dysplasia: a multicenter study.   J Am Coll Cardiol. 1997;30(6):1512-1520. doi:10.1016/S0735-1097(97)00332-XPubMedGoogle ScholarCrossref
3.
Omotoye  S , Junpaparp  P , McHugh  J ,  et al.  Cardiac sarcoidosis with prominent epsilon waves: a perfect phenocopy of ARVC.   JACC Case Rep. 2021;3(8):1097-1102. doi:10.1016/j.jaccas.2021.04.017PubMedGoogle ScholarCrossref
4.
Fontaine  GH , Duthoit  G , Li  G , Andreoletti  L , Gandjbakhch  E , Frank  R .  Epsilon wave on an electronic loop in a case of arrhythmogenic right ventricular dysplasia with myocarditis: an updated definition of the Epsilon wave.   Europace. 2017;19(7):1084-1090. doi:10.1093/europace/euw320PubMedGoogle ScholarCrossref
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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.

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