Unveiling Asymptomatic Atrioventricular Reciprocating Tachycardia in a Patient With Wolff-Parkinson-White Syndrome and Multiple Sclerosis.
Deitrich Gerlt, Ravi Patel, Michael Mogg et al.
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Case in brief
A 54-year-old woman with secondary-progressive multiple sclerosis was admitted with a complicated urinary tract infection. Her initial ECG showed sinus tachycardia without preexcitation, but telemetry captured a narrow-complex tachycardia at 220 beats per minute with hypotension; she denied palpitations, chest pain, and presyncope. Historical ECGs showed intermittent delta waves and short PR intervals, and an ECG during the event confirmed orthodromic atrioventricular reciprocating tachycardia. Synchronized cardioversion restored rhythm, followed by electrophysiological study and radiofrequency ablation of a left-sided anterolateral accessory pathway.
What made this case unusual
Despite hypotension during tachycardia, the patient reported no typical alarm symptoms. Her resting ECG also lacked preexcitation, while prior tracings documented intermittent accessory-pathway conduction.
Diagnostic / clinical pearl
A resting ECG without delta waves does not exclude an intermittently conducting accessory pathway. Telemetry and review of prior ECGs can reveal the substrate when an acute tracing captures tachycardia.
Why it matters
In this patient with multiple sclerosis, hemodynamic instability was not accompanied by subjective warning symptoms, underscoring the value of objective rhythm monitoring when symptom perception may be impaired.