ECG Challenge

ECG Section Editors

Authors: Andrés F. Miranda-Arboleda, MD, Cengiz Burak, MD, Adrian Baranchuk, MD

Non-prodromal syncope and frequent premature ventricular contractions

An 81-year-old male with a previous history of coronary artery disease (CAD), hypertension, and frequent premature ventricular contractions (PVC) presented to the emergency department with 2 episodes of non-prodromal syncope lasting less than 1 minute and recurrent presyncopal episodes. He denied chest pain, angina, palpitations, or heart failure symptoms. His recent cardiovascular work-up showed a normal left ventricle ejection fraction of 58% without other relevant abnormalities on the echocardiogram. A 48-hours Holter monitor showed frequent PVC with a burden of 26%, 2 predominant morphologies, and episodes of ventricular bigeminy. An angiogram performed 4 months before his presentation showed a 99% lesion in the mid-left anterior descending artery that was treated with percutaneous coronary intervention.

His vital signs on arrival showed mild bradycardia with a heart rate of 56 bpm, but they were otherwise normal. Laboratory work-up was unremarkable and did not reveal any potential explanation of syncope. The electrocardiogram (ECG) obtained in the emergency department is shown in figure 1A.

The patient was on bisoprolol 10 mg once daily which was discontinued, 72 hours after his admission he continued presenting similar episodes on telemetry (figure 1B).

figure 1 600