eISSN: 1896-9151
ISSN: 1734-1922
Archives of Medical Science
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vol. 13
Letter to the Editor

An unusual etiology of torsade de pointes-induced syncope

Marco Morosin
Ermanno Dametto
Federica Del Bianco
Marco Brieda
Gian L. Nicolosi

Arch Med Sci 2017; 13, 3: 686–688
Online publish date: 2017/04/20
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An 80-year-old woman was admitted to our Emergency Department because of syncope. The patient had no family history of sudden deaths or a medical history of depressive disorder, and she did not smoke or use illicit drugs. In the previous year, her daily medications included acetylsalicylic acid, delapril, simvastatin, vitamin D3 and a daily dose of 50 mg of fluvoxamine. The patient was lucid and cooperative and reported taking all tablets regularly. Repeated episodes of dizziness and transient loss of consciousness (T-LOC) occurred in the months preceding admission. At 4 p.m. on the day of admission, the patient had another episode of T-LOC while sitting on the bed, witnessed by her husband. At the Emergency Department, telemetry recorded in lead III several runs of self-terminating torsade de pointes (TdP) ventricular tachycardia with concomitant T-LOC (Figure 1). Prompt administration of IV magnesium (1 g IV bolus followed by continuous infusion of 0.5 g/h) and IV lidocaine (50 mg IV bolus followed by maintenance IV infusion of 1 mg/min) was performed. Physical examination was unremarkable. A 12-lead electrocardiogram (ECG) showed sinus rhythm, 59/min, incomplete left bundle branch block and a prolonged rate-corrected QT interval (QTc) of 0.51 s (Figure 2). We measured the QT interval from the onset of the QRS complex to the end of the T wave and used Bazett’s formula to correct the QT interval: QTc = QT/(R-R interval)½ [1]. Blood tests, electrolytes included, were normal. Transthoracic echocardiogram showed a left ventricle normal in size, moderate ventricular hypertrophy and normal regional function. Left ventricular ejection fraction was 54%. Color Doppler examination revealed mild mitral regurgitation and mild to moderate tricuspid regurgitation. Coronary angiography ruled out significant coronary artery disease (stenosis > 50%). Although the patient was not taking any known QT-prolonging medications, fluvoxamine was believed to be the likely cause of the prolonged QT interval and the malignant arrhythmia. Fluvoxamine was thus discontinued and in the subsequent 36 h the patient had three other TdP episodes, one of them requiring a DC shock. In the next days, serial ECGs indicated a stable sinus rhythm with progressive normalization of the QTc interval. No other ventricular arrhythmias were observed. The patient was discharged home and instructed not to take fluvoxamine. After a month, a 7-day ambulatory ECG recorded a single episode of an...

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