Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for evaluation of exertional syncope/presyncope triggered by emotional stress or physical activity. History is significant for palpitations and documented bidirectional ventricular tachycardia (BVT) or polymorphic ventricular tachycardia (PVT) during exercise stress testing. Family history is positive for sudden cardiac death (SCD) or unexplained syncope in first-degree relatives. No structural heart disease identified on echocardiography or cardiac MRI.
Clinical Examination Findings
Cardiovascular examination reveals regular rate and rhythm at rest. No murmurs, rubs, or gallops. Peripheral pulses are symmetric and full. Neurological examination is non-focal. Baseline resting ECG shows normal sinus rhythm, normal QTc interval, and absence of structural abnormalities. Physical findings are typically unremarkable in the resting state, emphasizing the necessity of provocative testing.
Treatment Protocol
Initiate long-term therapy with non-selective beta-blockers (e.g., Nadolol or Propranolol) as first-line treatment. Consider Flecainide as an adjunct for refractory cases. Implantable Cardioverter-Defibrillator (ICD) is indicated for patients with history of cardiac arrest or recurrent syncope despite optimal medical therapy. Left Cardiac Sympathetic Denervation (LCSD) may be considered in high-risk patients with breakthrough arrhythmias.