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.