Case presentation
A 63-year-old man with a past medical history significant for hypertension, type 2 diabetes mellitus, prostate cancer and class two obesity (BMI 38.9) was admitted from an outside facility for altered mental status. The patient was nonverbal, tachycardic and hypertensive at the outside facility. Brain MRI did not reveal any acute intracranial finding and a CT angiogram of the head and neck showed no vascular occlusion or significant stenosis. Shortly after arrival at our hospital the patient had a tonic-clonic seizure and was noted to have a pronounced facial droop. On physical exam the patient was tachycardic at 139 bpm, tachypneic to 35 per minute, febrile with a temperature of 100.6ºF and hypertensive with a blood pressure of 184/115 mmHg. ECG at this time showed sinus tachycardia. Initial lab work was unremarkable. Permissive hypertension was allowed due to possible stroke. Patient was emergently intubated for decreased responsiveness and transferred to the medical ICU.
On day three of admission the patient developed a narrow complex tachycardia that was initially noted on cardiac telemetry. Electrolytes and troponin levels at that time were unremarkable. ECG obtained at this time is shown in Figure 1. The differential diagnosis of this long RP point included atrial flutter, atypical fast-slow AVNRT, orthodromic AVRT and supraventricular tachycardia. The patient was subsequently started on 25ug/min/kg Esmolol drip and the dose was later increased to 50ug/min/kg due to consistent tachycardia of 80-120 bpm. He was later transitioned to 50 mg oral Metoprolol every 6 hours and 30 mg oral Diltiazem every 6 hours. Adequate rate control of 70-80 bpm was eventually achieved. The tachycardia was felt to be related to his acute illness. The patient improved clinically over the following ten days and no further episodes of SVT occurred.