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You are seeing a 15-year-old boy who collapsed during basketball practice. The president of the school’s pre-med club grabbed the AED in the gym and successfully defibrillated him. In the ED, he is now conscious, his vital signs are: temp 37.5 C, HR 90, RR 20, BP 110/70, pulse ox 97% on room air. His cardiopulmonary exam is not revealing. He has no prior personal history of syncope or heart disease but his maternal uncle died suddenly of unknown causes at age 24 years while training for a half marathon. The EKG shows T-wave inversions, a prolonged S-wave upstroke in V1-V3, and epsilon waves.
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February 3, 2026 at 10:12 pm
D) Admission for monitoring and placement of an implantable cardioverter defibrillator
The EKG changes described are indicative of Arrhythmogenic Right Ventricular Dysplasia cardiomyopathy, a rare (1:5000) genetic (Autosomal Dominant with variable penetrance) disorder resulting in replacement of cardiac muscle with fibrofatty tissue. Patients may present with palpitations, fatigue, syncope, and cardiac arrest, usually associated with exercise. Epsilon waves are small amplitude potentials after the QRS and before the onset of the T wave and are seen in ~50%. Other EKG findings include T-wave inversions in V1-V3, prolonged QRS in right precordial leads, and prolonged S-wave duration > 55 msec in V1-V3. Patients must restrict exercise and are treated with Beta-blockers and ICD placement. Hypokalemia can result in U waves. Hypercalcemia can result in Osborn waves. Isoproterenol and quinidine are used to treat Brugada syndrome. Wolff-Parkinson-White syndrome produces delta waves and may be treated with ablation of the accessory pathway.