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An unusual case of palpitations

BMJ 2009; 338 doi: (Published 12 February 2009) Cite this as: BMJ 2009;338:a3087
  1. Simon W Dubrey, consultant cardiologist,
  2. Sanjay K Kohli, specialist registrar in cardiology,
  3. Paresh A Mehta, specialist registrar in cardiology,
  4. Richard Grocott-Mason, consultant cardiologist
  1. 1Hillingdon Hospital, Uxbridge, Middlesex UB8 3NN
  1. Correspondence to: S K Kohli skkohli{at}

    A 66 year old white man presented with a three year history of intermittent frequent (daily) palpitations and associated malaise, but no syncope. He was taking no drugs and had no family history of arrhythmia or of unexplained, sudden, or premature death. Clinically he was afebrile, in sinus rhythm at 60 beats/min, had blood pressure of 130/80 mm Hg, and had normal heart sounds. Serum electrolytes, including magnesium, and haematology and hepatic and thyroid function tests were normal. His electrocardiogram (ECG) is shown in the figure 1. A seven day ECG event recorder showed two episodes (of 16 and 17 hours’ duration) of spontaneous atrial fibrillation at rates of up to 160 beats/min. These episodes coincided with symptoms. Chest x ray and cardiac imaging were entirely normal.


    • 1 What are the most striking abnormalities depicted on the ECG in the figure?

    • 2 What syndrome is associated with the characteristic features shown in the ECG?

    • 3 What is the aetiology of this syndrome?

    • 4 What are the associations and sequalae of this condition?

    • 5 …

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