Factitious Ventricular Tachyarrhythmia Outbreak

Abstract

Listen

Translate article

J ULY 22-23, 2009: A 23-YEAR-OLD MALE PATIENT with a history of syncope was seen at a small community hospital. The patient described an unwitnessed episode of syncope that occurred at rest. The onset of syncope was sudden, and the recovery was prompt. It was unclear how long he was unconscious. He had no injury. The patient had a history of hypertension and hyperlipidemia, a family history of premature coronary artery disease, and asthma from childhood. He was taking amlodipine, 5 mg/d, and atorvastatin, 40 mg/d. Findings from physical examination were unremarkable. The electrocardiogram showed no abnormality. The patient was admitted to the telemetry unit for monitoring. At 11:43 PM on the night of admission, the telemetry alarm went off indicating “ventricular tachycardia (VT) 235 bpm [beats per minute],” lasting for approximately 15 seconds (Figure 1). The episode was not witnessed, but the patient reported loss of consciousness. Ventricular tachycardia was diagnosed by the attending physician, and the patient was started on therapy with amiodarone and metoprolol. The standard 12-lead electrocardiogram (ECG) showed no abnormality suggestive of cardiac ischemia, and troponin levels were not elevated. The patient complained of chest pain and requested narcotic analgesics. When the narcotic analgesics were denied, the patient discharged himself from the hospital. July 23-25, 2009: The same patient presented to another hospital with the same history and was admitted to the coronary care unit (CCU) for monitoring. Multiple episodes of VT alarms were seen on telemetry, with reported syncope by the patient. All the episodes were nonsustained, and they occurred at nighttime and were unwitnessed. The patient again requested narcotic analgesics for chest pain and discharged himself from the hospital when the narcotics were denied. The 12-lead ECG and troponin levels were normal again. Findings from transthoracic echocardiography performed in that hospital were normal. Questions: Does this patient have ventricular tachyarrhythmia? How can you verify your diagnosis?