Wide-Complex Tachycardia in a Patient With Coronary Disease—Quiz Case

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A 55-YEAR-OLD MAN WITH A HISTORY OF hypercholesterolemia and symptomatic premature ventricular complexes treated with a -blocker was admitted to an outside hospital with acute-onset left-sided chest pressure, palpitations, and lightheadedness. Paramedics at the scene obtained a 12-lead electrocardiogram (ECG) revealing a wide-complex tachycardia at 248 beats per minute (Figure 1), which self-terminated as the patient was being prepared for direct-current cardioversion. The patient was then treated with chewable aspirin and intravenous lidocaine. In the emergency department he reported recurrent palpitations, and a repeated ECG showed atrial fibrillation with occasional wide QRS complexes that resembled the clinical tachycardia (Figure 2). Intravenous heparin sodium and amiodarone infusions were initiated. Cardiac biomarkers showed a mildly elevated level of troponin T (0.08 ng/mL [0.08 g/L]). Transthoracic echocardiography showed mild global left ventricular dysfunction with an ejection fraction of 45%. Urgent cardiac catheterization revealed an 80% proximal lesion in the left anterior descending artery and a 90% right coronary artery lesion that were treated with the implantation of 2 everolimus-eluting stents. The patient continued to have runs of wide-complex tachycardia after revascularization, and he was transferred to our facility for possible implantable cardioverterdefibrillator (ICD) with the diagnosis of sustained ventricular tachycardia (VT) in the setting of ischemic heart disease and a mildly depressed ejection fraction. Questions: What is the most likely diagnosis of the tachycardia seen in Figure 1? Should this patient receive an ICD?