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Endgames Case report

Transient loss of consciousness and a heart murmur

BMJ 2009; 339 doi: (Published 02 September 2009) Cite this as: BMJ 2009;339:b3323
  1. Christoph Kiblböck, senior house officer1,
  2. Wilhelm Schützenberger, associate professor 2,
  3. Jürgen Kammler, consultant cardiologist 2,
  4. Johannes Demmer, consultant surgeon 3,
  5. Franz Leisch, professor 2
  1. 1Academic Teaching and General Hospital Linz, 4020 Linz, Austria
  2. 2Department of Internal Medicine I, Cardiovascular Division, Academic Teaching and General Hospital Linz
  3. 3Department of Cardiovascular and Thoracic Surgery, Academic Teaching and General Hospital Linz
  1. Correspondence to: C Kiblböck christoph.kiblboeck{at}

    A 28 year old white woman was admitted after transient loss of consciousness. She remembered repeatedly lifting her neighbour’s child and finding herself on the floor the next moment. She had no nausea, sweating, or blurred vision before or after the event. Her husband confirmed that she had suddenly stopped in her movement, fallen down, and fully recovered within moments. She had never experienced such an episode before. However, she had experienced chest pain during physical exertion in the past three months. She had no previous medical history, an unremarkable family history, and was not taking medication.

    On physical examination she was alert and oriented, with a heart rate of 70 beats/min and a blood pressure of 130/80 mm Hg. She had no signs of a tongue bite, injury, or incontinence. On auscultation, she had a midsystolic murmur over the right second intercostal space, with radiation into both carotid arteries. Electrocardiography showed a sinus rhythm with biphasic T-waves in III and aVF. Full blood count, electrolytes, glucose, renal function, liver function, and C reactive protein were normal. Her erythrocyte sedimentation rate was 22 mm/h (normal <11 mm/h).


    • 1 What is the differential diagnosis in a young woman with these symptoms?

    • 2 What investigation should be ordered next?

    • 3 The patient had a cardiac myxoma. What are the clinical signs, potential risks, and complications of that rare disease?

    • 4 How should it be managed and what is the prognosis?


    Short answers

    • 1 A transient loss of consciousness, chest pain on exertion, and a heart murmur are suspicious of a cardiac syncope.

    • 2 The next diagnostic step should be transthoracic echocardiography.

    • 3 Patients with a cardiac myxoma may be asymptomatic or they may present with one or more of the classic triad of cardiac, embolic, or systemic signs.

    • 4 The treatment of choice is …

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