You are on call and you have your first admission at 6:00 pm. You go down to the ER to do your H & P. She is a 56 yo female whose chief complaint is "syncope". She was in her usual state of health until this afternoon when she was walking across the street with her friend when all of a sudden she became diaphoretic, felt her heart "racing out of my chest", and lost conciousness for a few minutes. She sustained no injuries thanks to her friend who caught her. She did not become incontinent, she had no warning of the attack, did not have any witnessed signs of seizure, has no history of seizure. She recalls only feeling sweaty and her heart pounding and than "blacking out". When she came to, she was mildly disoriented but after a few minutes felt OK. Her friend was concerned and called EMS. On arrival she was already concious and when they through the paddles on her see her rhythm she was back in sinus. She states that she had this happen to her 2 previous times in the same fashion, sudden onset with diaphoresis, loss of conciousness however the previous times she did not have the palpitations that she experienced today. Her family history is non contributory because she was adopted and does not know her family history. Physical exam is with in normal limits, no carotid bruits present, no post ictal state. She takes Metformin for DM II, Norvasc for HTN, Allegra for Seasonal Allergies and Celebrex for osteoarthritis. Xray is unremarkable except for some borderline cardiomegaly. You have 3 EKG's to look at, todays admission EKG, and the EKG's from her first episode which she came to the ER for and an EKG from her cardiologist's office for follow up from her first episode. What if any finding is present on these EKG's which warrants further investigation?

Admission EKG Click Here for Better Quality Image

EKG post first Episode Click Here for Better Quality EKG

EKG from follow up visit to cardiologist Click Here for Better Quality Image

The key finding in all three is a prolonged QT with the subtle finding of notched or bifid t waves. With the entire clinical picture of palpitations, syncope, diaphoresis and prolonged qt with bifid t waves, she most likely is suffering from a tachy arrhythmia triggered by the prolonged QT which she was lucky to survive 3 times!! Bifid T waves also are a clue to the diagnosis because they have an association with some cardiac syndromes one of them being a potassium channel defect leading to congenital prolonged QT syndrome. Long QT syndrome patients are at high risk for malignant arrhythmias such as Torsades and Sudden Death.

So practically speaking we are trying to figure out why she had syncope. In this case cardiac cause is high on the differential. The first thing to do would be check her med list for any drugs that prolong the QT and none of them do. The next thing would be to try and find out how long she has had the prolonged QT. With the three EKG's we have, the first one from 5 months ago, we establish that she has had this consistent EKG finding of long qt and bifid t wave for at least 5 months. She has no prior records available because she moved to the area last year from another state. So with this history and EKG findings, EP was consulted and she had a EP study done. She was inducible to V-Tach and got herself an AICD which probably will save her life. A rare zebra!!