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Challenges in Clinical Electrocardiography |

Syncope:  A Tale of Two Triggers

David F. Katz, MD1; Paul D. Varosy, MD1,2; Frederick A. Masoudi, MD, MSPH1
[+] Author Affiliations
1Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
2Eastern Colorado VA Medical Center, Denver
JAMA Intern Med. 2013;173(16):1543-1544. doi:10.1001/jamainternmed.2013.7750.
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A 60-year-old man was evaluated for recurrent syncope. He had a history of hepatitis C and hypothyroidism treated with levothyroxine. He was treated with methadone for opiate dependency. He had no history of cardiovascular disease. For 6 months he noted increasing urinary frequency and difficulty initiating urination. Over 1 month he experienced 10 episodes of syncope that occurred while urinating. He described a prodrome of diaphoresis and lightheadedness. Rapid palpitations preceded abrupt loss of consciousness, which he regained after 1 to 2 minutes. He had no family history of syncope or sudden death.

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Figure 1.
Presenting Electrocardiogram
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Figure 2.
Bradycardia With QT Prolongation to Longer Than 600 Milliseconds and Premature Ventricular Complexes (PVCs) During Micturition

In the setting of such bradycardia (A), a PVC may initiate torsades de points, exemplified by the twisting appearance of the QRS complexes (B).

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