JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
ECG CASE OF THE MONTH
Syncope in a 70-Year-Old Man with Aortic Stenosis and Carotid Sinus Hypersensitivity
Avaneesh Jakkoju, MD, Vishnupriya Kuchana, MD, Rakesh Jakkoju, MD, Pramilla Subramaniam, MD, and D. Luke Glancy, MD
CASE PRESENTATION
A 70-year-old man with a history of high blood pressure and a two-vessel coronary arterial bypass operation together with mitral valvular annuloplasty for mitral regurgitation some nine years earlier came to the emergency department (ED) after losing consciousness and falling off a ladder. He had had no warning symptoms before the syncopal episode. He was unconscious for only a few seconds and then briefly felt confused. He was able, however, to drive himself and his wife to the ED. He admitted to having a dizzy spell a day earlier while pushing his shopping cart in a grocery store.
In the ED, his blood work, including a comprehensive metabolic profile, a complete blood count, and cardiac markers, was normal. His electrocardiogram was normal except for meeting one set of criteria for left ventricular hypertrophy (Figure 1).
Figure 1. Twelve-lead electrocardiogram recorded on a 70-year-old man soon after a syncopal episode shows sinus rhythmand is normal except for meeting criteria of the Lewis index: (RI+SIII) – (RIII+SI) ≥ 1.7 mV, the oldest ECG criteria for left ventricular hypertrophy.²
An echocardiogram and cardiac Doppler study showed normal left and right ventricular function and no evidence of mitral stenosis or regurgitation. The aortic valve was heavily calcified, and the peak systolic flow velocity across it was 3.56 m/s with a calculated mean systolic pressure gradient of 30 mmHg and an aortic valve area of 1.56 cm.² Right carotid sinus massage did not cause symptoms or ECG changes. Left carotid sinus massage, however, caused the patient to feel dizzy and become unresponsive for a few seconds, and his ECG showed sinus arrest with a 3.6 s pause (Figure 2).
128 La State Med Soc VOL 170 JULY/AUG 2018
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