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Non-sustained ventricular tachycardia during carotid massage

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Carotid sinus massage is a useful bedside test in the evaluation of patients with syncope and in the diagnosis and possible termination of certain types of supraventricular tachycardia. The most frequent complication related to carotid massage is cerebrovascular accident, particularly in elder patients. We present a case of non-sustained ventricular tachycardia (nsVT) provoked by carotid massage.  A 41 year old female patient with a history of myocardial infarction and hypertension was referred for evaluation of repeated episodes of non-documented presyncope and syncope. Standard 12 lead ECG showed sinus rhythm, PQ 160 ms, no bundle branch block morphology, and pathologic Q waves in inferior leads. Left ventricular ejection fraction estimated by echocardiography was 40%. Carotid massage resulted in a 5160 ms sinus pause, and the next sinus beat was followed by a monomorphic nsVT after a 3040 ms pause. The ventricular tachycardia lasted 9 beats at a rate of 140 bpm, and terminated spontaneously (see fig). During a subsequent 24 hour Holter monitoring an episode of asymptomatic monomorphic nsVT (11 beats, 130 beats/min) was recorded. The patient gave no consent for coronary angiography but agreed to undergo electrophysiology testing, by which only a 4 beat run of nsVT could be induced using an aggressive stimulation protocol (two stimulation sites, three drive train, up to three extrastimuli, isoproterenol). Since the syncope episodes were more consistent with bradycardia caused by carotid sinus hyperaesthesia and there was no inducible ventricular tachycardia, the patient was treated with a dual chamber pacemaker and a β blocker.  The present case indicates that carotid massage may result in ventricular arrhythmia. If it is anticipated and prompt treatment is available, carotid massage should remain a simple and useful test.