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Endgames Case Review

A man with palpitations

BMJ 2024; 385 doi: (Published 02 May 2024) Cite this as: BMJ 2024;385:e076965
  1. Qinghua Chang, attending physician12,
  2. Changjun Li, resident physician13,
  3. Yuanzhe Jin, professor1
  1. 1Department of Cardiology, The Fourth Affiliated Hospital of China Medical University, Liaoning, China
  2. 2Department of Cardiology, The First Affiliated Hospital of Jinzhou Medical University, Liaoning, China
  3. 3Department of Gerontology, The First Affiliated Hospital of Jinzhou Medical University, Liaoning, China
  1. Correspondence to: Y Jin yzjin{at}

A man in his 80s presented to the emergency department with recurrent episodes of chest tightness, shortness of breath, and palpitations, which had become worse over the previous week. He was a cigarette smoker and had a history of hypertension. On initial evaluation he had a heart rate of 84 beats/min and blood pressure of 110/70 mm Hg. His lower legs were oedematous. Laboratory test result for brain natriuretic peptide was 1869.20 ng/L (reference range <100 ng/L) and for troponin I was 0.0210 μg/L (reference range 0-0.0340 μg/L). Transthoracic echocardiography showed biatrial and biventricular dilations (left > right), left ventricular systolic dysfunction, trivial mitral regurgitation, mild pericardial effusion, and a left ventricular ejection fraction of 30%. A 12-lead electrocardiogram (ECG) was obtained on admission (fig 1). During hospital admission, the patient experienced palpitations, and electrocardiography was repeated (fig 2).

Fig 1

Initial electrocardiogram

Fig 2

Repeated electrocardiography during palpitations showed atrial flutter (arrows …

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