Syncope: An Uncommon Presentation of Ischemic Cardiomyopathy
Syncope: An Uncommon Presentation of Ischemic Cardiomyopathy
A case report of an uncommon presentation of ischemic cardiomyopathy is described. The current evidence regarding risk stratification, diagnosis, and management of cardiac-related syncope is summarized and then applied to the current presentation. Conclusions and clinical implications are discussed.
A 53-year-old man presented to the emergency department (ED) for new episode of syncope. The episode occurred at work after prolonged standing and was accompanied with sudden palpitations and blurred vision. A few minutes later, he woke with a coworker by his side and was transported to the ED. Notably, he was exhausted at the time of the attack but reported the loss of consciousness was transient and that he recovered without any residual limitations. He had worked in constructions for 20 years and denied any medications use or cardiac disease; however, he was a heavy smoker for 30 years. A detailed health history revealed that his father died of a myocardial infarction (MI) at age 60.
During the physical exam he was alert and oriented, his supine blood pressure (BP) was 120/60 mmHg and his standing BP was 115/55 mmHg, lungs were clear, and there was no abnormal heart sounds or carotid bruits. Motor and sensory functions were intact during the neurologic exam, and head-up tilt test was negative. The complete blood count and comprehensive metabolic panel were within normal limits, and the cardiac enzymes were negative. His lipid panel was abnormal; specifically his triglycerides and low-density lipoprotein (LDL) were 316 and 135 mg/dL, respectively. The chest X-ray was not clinically significant, and the standard 12-lead electrocardiogram (ECG) showed normal sinus rhythm at 75 beats per minute with pathologic Q waves and T wave inversion in leads II, III, aVF, and V5-V6 (Figure 1).
(Enlarge Image)
Figure 1.
The initial 12-Lead ECG in the Emergency Department
Shows normal sinus rhythm at 75 beats per minute with pathologic Q waves and T wave inversion in leads II, III, aVF, and V5-V6
The patient was admitted to the hospital for further evaluation, and an urgent echocardiogram revealed cardiomyopathy with an ejection fraction (EF) of 35%; there was no valvular heart disease. The patient then underwent a diagnostic coronary angiogram that revealed triple vessel disease (right coronary artery, left anterior descending artery, and circumflex coronary artery blockages at 95%, 50%, and 100%, respectively). Myocardial viability studies indicated that coronary artery bypass surgery would be unfavorable. Given his poor EF, the patient eventually underwent implantable cardioverter-defibrillator (ICD) placement and was discharged home with ambulatory Holter monitoring for 24 hours, which revealed no major arrhythmias. No recurrent syncopal episodes were reported.
Abstract and Introduction
Abstract
A case report of an uncommon presentation of ischemic cardiomyopathy is described. The current evidence regarding risk stratification, diagnosis, and management of cardiac-related syncope is summarized and then applied to the current presentation. Conclusions and clinical implications are discussed.
Introduction
A 53-year-old man presented to the emergency department (ED) for new episode of syncope. The episode occurred at work after prolonged standing and was accompanied with sudden palpitations and blurred vision. A few minutes later, he woke with a coworker by his side and was transported to the ED. Notably, he was exhausted at the time of the attack but reported the loss of consciousness was transient and that he recovered without any residual limitations. He had worked in constructions for 20 years and denied any medications use or cardiac disease; however, he was a heavy smoker for 30 years. A detailed health history revealed that his father died of a myocardial infarction (MI) at age 60.
During the physical exam he was alert and oriented, his supine blood pressure (BP) was 120/60 mmHg and his standing BP was 115/55 mmHg, lungs were clear, and there was no abnormal heart sounds or carotid bruits. Motor and sensory functions were intact during the neurologic exam, and head-up tilt test was negative. The complete blood count and comprehensive metabolic panel were within normal limits, and the cardiac enzymes were negative. His lipid panel was abnormal; specifically his triglycerides and low-density lipoprotein (LDL) were 316 and 135 mg/dL, respectively. The chest X-ray was not clinically significant, and the standard 12-lead electrocardiogram (ECG) showed normal sinus rhythm at 75 beats per minute with pathologic Q waves and T wave inversion in leads II, III, aVF, and V5-V6 (Figure 1).
(Enlarge Image)
Figure 1.
The initial 12-Lead ECG in the Emergency Department
Shows normal sinus rhythm at 75 beats per minute with pathologic Q waves and T wave inversion in leads II, III, aVF, and V5-V6
The patient was admitted to the hospital for further evaluation, and an urgent echocardiogram revealed cardiomyopathy with an ejection fraction (EF) of 35%; there was no valvular heart disease. The patient then underwent a diagnostic coronary angiogram that revealed triple vessel disease (right coronary artery, left anterior descending artery, and circumflex coronary artery blockages at 95%, 50%, and 100%, respectively). Myocardial viability studies indicated that coronary artery bypass surgery would be unfavorable. Given his poor EF, the patient eventually underwent implantable cardioverter-defibrillator (ICD) placement and was discharged home with ambulatory Holter monitoring for 24 hours, which revealed no major arrhythmias. No recurrent syncopal episodes were reported.
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