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Cardiology

Irregular Rhythm in a Middle-Aged Man Presenting With New-Onset Heart Failure

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

1 Credit CME

JAMA Cardiology

Published Online: November 15, 2023

JAMA Cardiology Clinical Challenge

Article Information and Disclosures

Hussam Ali, MD¹;

Ilaria Passarelli, MD²;

Riccardo Cappato, MD¹

Author Affiliations

¹Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
²Cardiology Department, Bassini Hospital, Cinesello Balsamo, Milan, Italy

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A man in his 50s underwent clinical assessment for a 4-month history of recurrent palpitations, fatigue, and progressive exertion dyspnea. He had no history of cardiac disease, and there was no family history of heart disease or sudden death. Physical examination revealed an irregular pulse and a systolic murmur at the heart apex. Holter monitoring and 12-lead electrocardiogram (ECG) recordings documented irregular narrow-QRS tachycardia in an incessant, repetitive fashion with heart rates up to 180 beats per minute and occasional short runs of wide-QRS tachycardia. Transthoracic echocardiogram showed a dilated and diffusely hypokinetic left ventricle (ejection fraction, 30%) associated with moderate to severe functional mitral regurgitation. Blood test results were within normal limits, including thyroid function, C-reactive protein, and myocardial enzymes. The patient was hospitalized, and medical therapy was initiated, including ACE inhibitors, mineralocorticoid receptor antagonists, β-blockers, and diuretics. Coronary angiography revealed no significant coronary stenoses. A representative 12-lead ECG of the arrhythmia is shown in Figure 1.

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A man in his 50s underwent clinical assessment for a 4-month history of recurrent palpitations, fatigue, and progressive exertion dyspnea. He had no history of cardiac disease, and there was no family history of heart disease or sudden death. Physical examination revealed an irregular pulse and a systolic murmur at the heart apex. Holter monitoring and 12-lead electrocardiogram (ECG) recordings documented irregular narrow-QRS tachycardia in an incessant, repetitive fashion with heart rates up to 180 beats per minute and occasional short runs of wide-QRS tachycardia. Transthoracic echocardiogram showed a dilated and diffusely hypokinetic left ventricle (ejection fraction, 30%) associated with moderate to severe functional mitral regurgitation. Blood test results were within normal limits, including thyroid function, C-reactive protein, and myocardial enzymes. The patient was hospitalized, and medical therapy was initiated, including ACE inhibitors, mineralocorticoid receptor antagonists, β-blockers, and diuretics. Coronary angiography revealed no significant coronary stenoses. A representative 12-lead ECG of the arrhythmia is shown in Figure 1.

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Article Information

Corresponding Author: Hussam Ali, MD, Arrhythmia and Electrophysiology Centre, IRCCS–MultiMedica Group, Via Milanese 300, 20099 Sesto San Giovanni, Milan, Italy (hussamali.ep@gmail.com).

Published Online: November 15, 2023. doi:10.1001/jamacardio.2023.4249

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References

Marrouche NF , Brachmann J , Andresen D , et al; CASTLE-AF Investigators. Catheter ablation for atrial fibrillation with heart failure. N Engl J Med. 2018;378(5):417-427. doi:10.1056/NEJMoa1707855 PubMed Google Scholar Crossref

Al-Khatib SM , Stevenson WG , Ackerman MJ , et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Circulation. 2018;138(13):e272-e391.PubMed Google Scholar

Otto CM , Nishimura RA , Bonow RO , et al; Writing Committee Members. 2020 ACC/AHA guideline for the management of patients with valvular heart disease. J Am Coll Cardiol. 2021;77(4):e25-e197. doi:10.1016/j.jacc.2020.11.018 PubMed Google Scholar Crossref

Peiker C , Pott C , Eckardt L , et al. Dual atrioventricular nodal non-re-entrant tachycardia. Europace. 2016;18(3):332-339. doi:10.1093/europace/euv056 PubMed Google Scholar Crossref

Huizar JF , Ellenbogen KA , Tan AY , Kaszala K . Arrhythmia-induced cardiomyopathy. J Am Coll Cardiol. 2019;73(18):2328-2344. doi:10.1016/j.jacc.2019.02.045 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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.