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A 73 year old woman presented to the emergency room having developed incoherent speech and weakness of her right leg. She was under investigation for recurrent presyncopal episodes and was wearing a 24 hour Holter monitor. Medication consisted of bendrofluazide (2.5 mg once daily) prescribed for hypertension. She reported a single episode of collapse with probable loss of consciousness. Examination revealed a mild right sided hemiparesis and expressive dysphasia. A computed tomographic scan of the head showed a left parietal wedge shaped area of low attenuation suggesting recent cerebral infarction. The resting 12 lead ECG showed atrial fibrillation at 90 beats/min and right bundle branch block. Blood biochemistry and haematology were normal.
The single channel Holter recording shows atrial fibrillation, at a rate of approximately 110 beats/min, with ST segment depression. With the precipitation of an “R on T” event (point a) ventricular fibrillation is initiated and continues for a period of 3 minutes and 7 seconds. This terminates spontaneously (point b) and is followed by a period of asystole, which persists for 21 seconds until the first QRS complex reappears. Atrial fibrillation then returns, the rate gradually increasing and presumably with this her cardiac output and recovery of consciousness.
The patient was admitted to the coronary care unit. Amiodarone was started as an antiarrythmic. Coronary angiography revealed severe three vessel disease and impaired left ventricular function. Coronary bypass surgery was performed and she has a made a good recovery with only a residual minor dysphasia.
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