Endgames Picture Quiz

A case of recurrent ventricular tachycardia

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2654 (Published 01 June 2011) Cite this as: BMJ 2011;342:d2654
  1. C Inglis, foundation year 1 doctor1,
  2. F Chedgy, medical senior house officer1,
  3. D C Howlett, consultant radiologist1
  1. 1Eastbourne District General Hospital, Eastbourne BN21 2UD, UK
  1. Correspondence to: C Inglis celineinglis{at}doctors.org.uk

A 76 year old woman collapsed at home after feeling ill and faint, with central chest pain radiating to both arms. She was found to be in pulsatile ventricular tachycardia by paramedics and her arrhythmia was converted to sinus rhythm with 100 mg of intravenous lidocaine. Her medical history included an anteroapical myocardial infarction eight years previously and subsequent New York Heart Association class III heart failure with moderate to severe systolic dysfunction. Before this admission she had been maintained on lisinopril 20 mg once daily, isosorbide mononitrate 40 mg once daily, frusemide 40 mg twice daily, warfarin, atorvastatin 20 mg once daily, digoxin 250 µg once daily, carvedilol 6.25 mg once daily, and glyceryl trinitrate as needed. In the months before this episode she had experienced recurrent attacks of dizziness and palpitations and occasional episodes of anginal chest pain. Serial electrocardiographs showed sinus rhythm, QRS duration of 125 ms, septal Q waves, and non-dynamic 1 mm ST elevation unchanged from previous electrocardiographs. Cardiac enzymes were not raised. She had more episodes of ventricular tachycardia on the coronary care unit, however, and she underwent further treatment. Chest radiography (fig 1) was performed before she was discharged.


  • 1 What abnormalities are seen on the chest radiograph and what are the most likely causes?

  • 2 What is the most likely explanation for her arrhythmia?

  • 3 How should such patients be managed?


1 What abnormalities are seen on the chest radiograph and what are the most likely causes?

Short answer

The heart is enlarged with dilation of the left ventricle and left atrium (fig 2). Extensive curvilinear calcification is seen overlying the cardiac apex consistent with myocardial calcification within a longstanding left ventricular aneurysm. A left sided pacemaker and an implantable cardioverter defibrillator were fitted after further episodes of ventricular tachycardia occurred on the coronary care unit. These are also seen in the chest radiograph, with leads placed in …

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