Cardiac arrest in an (apparently) healthy heart: A case report of an undiagnosed arrhythmogenic cardiomyopathy

Arrhythmogenic cardiomyopathy is a rare and insidious disease that can be misdiagnosed with the common first-line diagnostic techniques. It can also primarily debut with sustained ventricular arrhythmias that can lead to cardiac arrest. We report the case of a 49-year-old triathlon athlete who during strenuous physical exercise experimented cardiac arrest. After successful resuscitation he was admitted to our unit: electrocardiogram, emergency echocardiogram, and coronary angiography did not show anything abnormal. Holter monitoring showed premature ventricular complexes with two different morphologies and cardiac magnetic resonance allowed us to make diagnosis of biventricular arrhythmogenic cardiomyopathy previously unrecognized. A subcutaneous implantable cardiac defibrillator was positioned for secondary prevention. Our case shows that in athletes a deep process of diagnostic screening is mandatory and this must include also cardiac magnetic resonance in case of element of clinical suspicion such as premature ventricular complexes at Holter monitoring and/or low voltages on limb leads in baseline 12‑lead electrocardiogram. A network of basic life emergency support measures is fundamental in every setting in which sport at competitive and non-competitive levels is performed.

Learning objectives

A deep diagnostic cardiologic screening for young athletes is important especially in case of premature ventricular complexes at electrocardiographic Holter monitoring and/or in clinical suspicion of an underlying cardiomyopathy. In selected cases the execution of cardiac magnetic resonance imaging is essential to permit the correct diagnostic assessment of a previously undiagnosed cardiomyopathy as the arrhythmogenic cardiomyopathy preventing dangerous (also lethal) clinical presentation.