DISCOVERING PALPITATIONS

NA is a 51 years old dyslipidemic man without previous cardiovascular history. It’s been for 2 years that occasionally transient palpitations appear but nothing has been made. He came to ED for palpitations after vomiting: the ECG showed sinus rhythm with transient NSVT then sinus rhythm again and SVT with ST alteration. Metoprolol 2.5mg ev and MRA ev were administered because of mild hypokalemia with benefit. Echocardiogram and chest X–ray were normal without drugs intake. During hospitalization we started bisoprolol 2.5mg po and anti–dyslipidemic therapy but we observed very frequently PVC and PSVC and symptomatic wide QRS complex sustained tachycardia paroxysms at 180 bpm without loss of consciousness, hypotension or electrolytic abnormalities and SVT 170 bpm unresponsive to BB and amiodarone. The stress test without BB evidenced early wide QRS complex sustained tachycardia at 220 bpm well hemodynamically tolerated: metoprolol 10mg ev administration showed a brief sinus rhythm and then a narrow QRS complex sustained tachycardia at 160 bpm with significantly ST underleveled so flecainide 150mg ev was given with cardioversion to sinus rhythm and slowly ST abnormality regression. Subsequent coronary angiography and cardiac magnetic resonance resulted normal. The electrophysiological study demonstrated AVRT with a left lateral pathway retroconduction with and without LBBB and subsequent short AF paroxysms: the left lateral pathway was ablated without complications but the high atrial electrical vulnerability with reproducible SVT and triggered AF paroxysms lead to ILR implantation. The patient was discharged without antiarrhythmic and anticoagulant therapy: during the follow up there’s no arrhythmic relapses evidence and the patient is asymptomatic. Never give up to looking for solutions about palpitations: accessory pathway happens when you least expect it.