68-year-old man with syncope and wide-complex tachycardia
A 68-year-old man with ischemic cardiomyopathy and an ejection fraction of 30% is brought to the emergency department after a sudden loss of consciousness while climbing stairs. He reports several weeks of palpitations but no chest pain. Blood pressure is 108/64 mm Hg, pulse is 184/min, and he is diaphoretic. ECG shows a regular wide-complex tachycardia. He remains awake but becomes lightheaded during the tracing. Which of the following is the most appropriate next step in management?
See the answer and explanation below:
Post-Call Recovery Reads
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A
Explanation
Clinical Pearl:
In an adult with structural heart disease, a regular wide-complex tachycardia should be treated as ventricular tachycardia unless proven otherwise. Hemodynamic instability, even without frank hypotension, is an indication for immediate synchronized cardioversion.
Explanation:
This patient has likely monomorphic ventricular tachycardia, suggested by prior myocardial scar, a regular wide-complex tachycardia, syncope, and evolving symptoms of poor perfusion. Current ACLS and cardiology guidance support immediate synchronized cardioversion for unstable tachyarrhythmia, and lightheadedness with diaphoresis after syncope represents instability even with a preserved blood pressure. Adenosine can be considered in selected stable regular wide-complex rhythms when supraventricular tachycardia with aberrancy is suspected, but that is not the safest next step here. Verapamil is contraindicated in presumed ventricular tachycardia because it can precipitate severe hypotension and collapse. Observation is inappropriate because this rhythm carries a high risk of deterioration, and carotid massage is used for stable narrow-complex SVT, not scar-related wide-complex tachycardia. The key is to treat first based on the clinical syndrome and rhythm pattern, not to delay for diagnostic certainty.
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