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A 39-year-old female referred for tilt table test as reported symptoms of palpitation and recurrent syncopal episodes.

During tilt-table test: the following note >> as showed on 12-lead EKGs.

What's your next step in management of this case?

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    • Interesting tracing. Never seen something like this before!

      Am not sure I can tell what is going on and if that is related to the patient's clinical presentation or now. Here are the main observations: 1.accelerated sinus rate with intermittent AV dissociation and accelerated junctional rate (isorhythmic dissociations). 2.Runs of non-sustained WQRS beats (mainly RBBB), many of them started with what looks like a "fusion" beat, which makes those wide beats likely NSVT.

      This is very unusual response to tilting. Orthostatic induced VT is extremely rare. Will need more evaluation before I can conclude based on this study alone. Needs echo, event monitor, also a stress test (for arrhythmia induction) and if all negative, won't be a bad idea to do a diagnostic EPS.

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      • The patient had multiple ED visits with syncopal episodes which I do agree might not be related.

        Echo was done at outside facility and reported normal LVEF 63% with moderate left ventricular dilation.

        Also, just completed 2 weeks event monitor at outside facility pending report.

        I saw the case this Friday and noted the above rhythm during tilt table test.

        My assumption was related to non sustained runs of fascicular tachycardia (although they were irregular). Initial beat has rbbb/LPFB morphology and subsequent beats have rbbb/LAFB morphology).

        I did prescribe verapamil and referral to EP to consider ablation procedure.

        I will keep you posted

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