Acute Coronary Syndrome Presenting as Sudden Cardiac Death

Dear Editor,

A 39-year-old chronic smoker, after recovering from COVID-19 pneumonia two months ago, presented with a recent brief history of restless angina. In the outpatient department, he suddenly collapsed, having hypotension and agonal respiration. A 12-lead ECG revealed polymorphic ventricular tachycardia (PVT) (Panel A). The ACLS (advanced cardiac life support) protocol was activated and PVT was immediately terminated using electrical cardioversion. Following successful resuscitation, ECG showed sinus rhythm, prolonged QT_c interval (569 milliseconds), and ST-T changes consistent with an anterior ST-elevation myocardial infarction (Figure 1, Panel B). Echocardiography showed apico-septal hypokinesia with a left ventricular ejection fraction of 45%. Coronary angiography revealed critical disease in the mid-left anterior descending artery (Panel C) that was successfully revascularized by implanting a 4 × 33 mm sirolimus-eluting stent (Panel D).

It is quite rare to record a 12-lead ECG of PVT or torsades-de-pointes due to the associated rapid hemodynamic collapse. This case underlines the importance of recognizing and prompting reversion of PVT, which may be the initial and only presentation of acute coronary ischemia, showcasing the rare opportunity to record a 12-lead ECG of ongoing PVT without any intervening sinus beat.

Figure 1.

A 12-lead index ECG shows irregular, rapid, chaotic rhythm with varying broad QRS complex morphologies suggestive of polymorphic ventricular tachycardia (panel A). Post-cardioversion ECG shows sinus rhythm with QS in V₁–V₃, ST-segment coving and T-wave inversions in precordial leads suggestive of anteroseptal infarct (panel B). Left coronary angiogram in AP caudal view shows 99% tubular stenosis (white arrow) in the mid-left anterior descending artery (LAD) (panel C). Final result after stenting the LAD lesion (panel D).