Intended for healthcare professionals

Endgames Spot Diagnosis

A young man with palpitations and pre-syncope

BMJ 2017; 359 doi: (Published 09 November 2017) Cite this as: BMJ 2017;359:j4846
  1. Debjit Chatterjee, consultant cardiologist
  1. Queens Hospital, Burton on Trent, UK
  1. Correspondence to D Chatterjee debjit.chatterjee{at}

A 20 year old man presented to the emergency department with palpitations lasting half an hour. He was also feeling dizzy and felt close to fainting. He denied any chest pain. He had no known cardiac history.

Examination revealed blood pressure of 70/50 mm Hg. Oxygen saturation was 91% on room air. There was no murmur on auscultation of the chest. The man underwent electrocardiography (ECG) (fig 1). What rhythm does the ECG show?

Fig 1 Electrocardiography (ECG) on presentation to the emergency department

Short answer

Atrial fibrillation with very fast ventricular response as a result of antegrade conduction through an accessory pathway (pre-excited atrial …

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