A Case of Intermittent Preexcitation and Palpitations: More than Meets the Eye

We discuss the case of a 22-year-old female who presented to the clinic experiencing recurrent palpitations. She was also found to have intermittent preexcitation on her electrocardiogram (ECG). Her palpitations were attributed to stress. Previously, she had gone to the emergency department a few times and was diagnosed with sinus tachycardia. Her ECG revealed a right-sided accessory pathway. Given her atypical finding of orthodromic reciprocating tachycardia, a 30-day event monitor was implanted, which revealed that one episode was correlated with sinus tachycardia, with a heart rate of 120 bpm. She mentioned experiencing other episodes that were severe, but she did not activate the monitor manually at the time of these incidents. After a long discussion with the patient about available management options for her symptoms, it was decided to proceed with long-term monitoring with an implantable loop recorder to gather better symptom–rhythm correlation data. At six months after surgery, the patient experienced multiple manually triggered transmissions from her device, which were all consistent with sinus tachycardia. She had no episode suggestive of any supraventricular tachycardia and is thus being treated for inappropriate sinus tachycardia. This case highlights the importance of gathering adequate symptom–rhythm correlation data before pursuing more invasive treatment options for an arrhythmic etiology in low-risk patients.