Early asymptomatic arrythmia detection using intermittent ECG in the diagnostic process – A case report

Abstract

Introduction: Asymptomatic arrythmias can result in adverse events including sudden cardiac death. Bradycardia is prevalent in active populations and can remain asymptomatic or become malignant. Pauses of six seconds in duration and syncope are the present criterion recommended for treatment. To the best of our knowledge, this is the first report supporting the use of intermittent ECG monitoring to identify an asymptomatic arrythmia associated with bradycardia which resulted in eventual placement of a pacemaker. Case presentation: The subject matter is a 31-year-old male recreational athlete who took chest and thumb ECGs intermittently throughout a 2-day period. On both days, abnormal rhythms were identified more than once in one of the leads. Follow up diagnostics included a 24-hour Holter revealing 6 isolated action potential durations, 2 isolated pre-ventricular contractions, 6 supraventricular ectopic beats, 2 ventricular ectopic beats, 28 bradycardic events and 18 pauses. At 6 month follow up, an insertable loop recorder identified 117 events with 112 pauses and 5 bradycardic events. Eleven of the pauses were of >6 seconds duration. A near syncope episode including symptoms of tunnel vision, nausea, diaphoresis and almost loss of consciousness resulted in hospitalization. The ECG at time of hospitalization showed normal sinus rhythm with ST-segment elevation and tall T waves. A dual chamber pacemaker was placed to prevent future episodes of syncope. Conclusion: The present case study highlights the need for additional objective criteria to identify patients requiring early management of asymptomatic bradycardia to prevent unnecessary hospitalization. Intermittent ECG assessment may provide an additional complimentary assessment which can regularly be utilized to monitor patients with asymptomatic arrythmia. De-conditioning may not be an option for treatment and waiting for syncope to occur leaves patients susceptible to sudden cardiac death or mortality as a result of uncontrollable circumstances at time of a near syncope episode. Development of additional monitoring processes and criteria for early pacemaker implantation are warranted.