Monday, December 14, 2020

A 45 year old smoker presents with palpitations, is discharged, and is found dead 2 days later

A 45 year old smoker presented with palpitations.  He had no other medical problems.  There was no syncope.  He was on no medications.

Unfortunately, no other information is available, but that is enough to provide an learning point.

Here is the EKG:

Do you see anything worrisome?

There are PVCs, and these might be the cause of the palpitations (whether they are indeed the source of the palpitations could easily be ascertained by asking the patient if the palpitations are still present during the ECG).  

However, there are wide QS-waves (0.8 ms) in III and aVF, and they have a fragmented QRS (extra spike in the middle of the Q-wave, down-up-down).  Fragmented QRS is defined as additional spikes within the QRS complex.  It is a sign of myocardial scar and a significant risk factor for serious dysrhythmia and sudden death.  

Although PVCs are not dangerous in the absence of other significant pathology, they are another clue that there may be myocardial scarring and PVCs are frequently the initiating stimulus for Ventricular Tachycardia (VT) and ventricular fibrillaton (VF) (and not only for polymorphic VT/Torsades). 

Clinical Course

The extent of the patient's ED evaluation was not provided.  

For instance, we don't know the character of the palpitations.  
"Was your heart beating fast?  Or just jumping around in your chest?"  
"Did you take you pulse during the palpitations?"  
"While the tech was recording your ECG, were you having the same symptoms?"  
"Did you feel as if you might pass out during the palpitations?"
"Was there shortness of breath or chest pain?"

In addition, electrolyte concentrations are not available, nor troponin.  But since he was discharged to home, let's assume they were normal.  

2 days later he was found dead.   No further details are available.

Although no details are available, it is a reasonable probability, or even high probability, that the patient suffered an arrhythmic death.  

In any case, it presents a learning opportunity.

The palpitations may have been ventricular tachycardia.  Myocardial scar, as evidenced by the inferior fragmented QRS, is a nidus for a primary ventricular dysrhythmia.  A recurrent dysrhythmia might be VF, or VT that degenerated into VF.

Palpitations as an ED chief complaint are the subject of an upcoming study. According to another study, palpitations comprise about 0.6% of ED visits, 1/4 of which result in hospital admissions.  1/3 are given "cardiac diagnosis."  

Diagnoses associated with palpitations are many, though among those without syncope, they are mostly non life-threatening, and include PACs, PVCs, SVT, atrial fibrillation/flutter, pre-excited and Ventricular tachycardia.  Of course atrial fib is particularly important because it can lead to stroke.  Some of the abnormal rhythms are still present on arrival to the ED, some are terminated.  It is the ones that are terminated which are obviously most difficult to diagnose, unless there are telltale signs on the 12-lead ECG such as Brugada, long QT, WPW, RV dysplasia, or HOCM.  Ventricular tachycardia (VT) is the most dangerous of these (except for WPW with atrial fib).

VT is commonly caused by not only the above named syndromes, but by myocardial scar from many pathologies, but most commonly from ischemic cardiomyopathy, due to myocardial scarring from previous MI.  

Such scarring is not always evident on the ECG, or it may manifest pathologic Q-waves.  But QRS fragmentation is a sign of myocardial scarring, so for this patient the ECG risk is quite high.

When to hospitalize

This patient would fall under "Primary electrical heart disease, suspected."  or "Severe structural heart disease, suspected."

In a patient with palpitations, Q-waves due to old infarction, especially those with a fragmented QRS should lead you to suspect structural heart disease and primary electrical heart disease.

Learning point
"Palpitations" is a common ED complaint and can usually be evaluated in the ambulatory setting unless associated with syncope (or perhaps presycope), or any of the above considerations (in the table).  If I saw such a patient with palpitations and a fragmented QRS, or even known previous myocardial infarction (MI) alone, (or also any patient with decreased LV function on point of care bedside echo), I would admit for further workup, which may include formal contrast echo, angiography, MRI, Stress testing, CT coronary angiography, or even electrophysiology study, depending on the cardiologist's evaluation.

More on Fragmented QRS

This paper found that a fragmented QRS in inferior leads is a particular high risk for sudden death: QRS fragmentation and the risk of sudden cardiac death in MADIT II


  1. Interesting commentary - I think fQRS is not even on the radar of most doctors (including myself). I find the approach of admitting all patients with a history of palpitations with either fQRS or - as you say - even a previous MI would not be standard practice. I'd be interested to see what the yield of this approach is, both in terms of pathology found as well as interventional outcomes (i.e. ICD use). I think it would be too conservative an approach for my local cardiology / general physician colleagues.

    1. The yield may be low, especially because during admission the patient may not have any dysrhythmias. On the other hand, this is so uncommon that it will not fill up your hospital. Think of all we do to save one life and admitting someone like this is much less resource intensive.


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