Asystole in a patient complaining of syncope, a case of paroxysmal ventricular standstill: a case report

¹“Coeur et vie” Foundation, Ndogbong, Douala, Cameroon, ²“Coeur et vie” Clinic, Ndogbong, Douala, Cameroon, ³Université des Montagnes, Faculty of Medicine, Banekane, Cameroon, ⁴Cameroon Cardiac Society, Yaounde, Cameroon, ⁵Faculty of Medicine and Biomedical Science, Yaounde, Cameroon, ⁶Douala General Hospital, Beedi, Douala, Cameroon, ⁷Faculty of Medicine and Pharmaceutical Science, Dschang, Cameroon, ⁸Faculty of Medicine and Pharmaceutical Science, University of Douala, Douala, Cameroon

^&Corresponding author
Etienne Verlain Fouedjio Kafack, “Coeur et vie” Foundation, Ndogbong, Douala, Cameroon

Introduction    

Syncope, one of the common presentations in the cardiac emergency department, is defined as a transient loss of consciousness followed by spontaneous recovery [1]. Although easily diagnosed, finding the aetiology can be difficult; three mechanisms are known as causes of syncope: orthostatic hypotension, neurogenic and cardiac origin [1]. The latter is less common than others and most often considered as Stokes-Adams attacks which are recurrent loss of consciousness due to atrioventricular heart block, ventricular tachycardia, or rarely ventricular standstill or a combination of these [2,3]. Syncope from cardiac origin could be life-threatening if not diagnosed promptly and managed. One life-threatening cause of syncope from cardiac origin, rare and difficult to diagnose is Paroxysmal Ventricular Standstill (PVS); it is a cardiac event in which there is no ventricular activity despite normal atrial functioning, often leading to cardiac arrest and syncope [4]. In the literature, few cases of syncope from cardiac origin have been reported. Moles et al. presented a case of PVS with nine seconds of asystole [4]. Adegoke et al. described PVS as a rare manifestation of syncope [2]. Sidhu et al. reported a 60-year-old healthy man surviving a ventricular standstill for 111 seconds [5]. We report a case of PVS in a patient with 2-year history of recurrent syncope.

Patient and observation     

Patient information: a 54-year-old male Cameroonian businessman with no relevant past medical history apart from a 2-year history of recurrent intermittent syncope. He consulted our hospital after presenting with a one-week history of death-like symptoms and dizziness. He described the death-like symptoms as a brief sensation of inability to breathe followed by body weakness of short duration.

Clinical findings: patient was conscious with pink conjunctivae. His blood pressure (BP) was 126/68mmHg, heart rate (HR) 75 beats per minute, respiratory rate (RR) 21 breaths per minute, Temperature 37.1°C, and SaO₂ 99% on room air. The neurological and cardiovascular examination was unremarkable.

Timeline of the current episode: March 2020: first episode of syncope; multiple labs investigation performed without obvious diagnosis; February 2022: referral to our hospital. March 2022: consultation in our setting, diagnosis made one week later.

Diagnostic assessment: a 12-lead ECG, transthoracic echocardiogram, and blood tests (CBC, electrolytes, T3, T4, TSH...) were ordered, and all results were normal except for white blood cells at 2350 cells/microliter. Following these results, a 24-hour cardiac activity monitoring at home using a Holter-ECG was initiated, and the patient was asked to come the next day for interpretation. The 24-hour cardiac monitoring revealed eleven seconds of asystole with atrial activity (P wave without ventricular activity) and a spontaneous return to sinus bradycardia afterward (Figure 1, Figure 2).

Diagnosis: based on the result and the clinical presentation, we confirmed a case of paroxysmal ventricular standstill.

Therapeutic interventions: patient was advised to undergo pacemaker placement.

Follow-up and outcome of interventions: the patient refused the management and decided to follow up with an alternative management. Loss of follow-up later.

Patient perspective: “I am happy to know my diagnosis after a long period of looking for the cause, but I am not ready to undergo any operation right now”.

Informed consent: the current study is part of the scientific project that was approved by the research ethics committee of the “Coeur et Vie” Clinic. All ethical principles were followed. The patient gave his consent.

Discussion     

Paroxysmal ventricular standstill, a rare cause of Stokes-Adam attacks [2] is characterised by asystole with normal activity of the atrium. Data on PVS are scarce, probably because the diagnosis is complex (usually diagnosed incidentally). Our patient had a 2-year history of recurrent syncope without an obvious diagnosis, and this is peculiar to paroxysmal ventricular standstill. Moles et al. reported having diagnosed PVS incidentally using a telemetry strip and a repeated ECG; the initial ECG showed sinus rhythm with no AV block [4]. This was the same in the case report of Jaiswal et al. where the 50-year-old patient presented with nausea, vomiting, and chest pain [6]. Although we assumed the patient´s symptoms to be a case of syncope, we could not assess it during clinical examination, we based our diagnosis on the previous medical report of syncope and the patient history. Another strong differential of PVS is the Ictal asystole. Lctal asystole is described as seizure-induced asystole, Sowden et al. described well a case of ictal asystole with a patient having a transient loss of consciousness [7].

For a case of paroxysmal ventricular standstill or ictal asystole to be diagnosed, there is a need for further evaluation. In most cases of PVS, Telemetry, Holter ECG or cardiac monitoring are the main diagnostic tools used. Benditt DG et al. proposed 06 diagnostic tools in case of syncope from cardiac origin: hospital monitoring, Holter ECG, heart monitoring, electrophysiological investigation, echocardiography, and stress test [1]. Once the diagnosis of paroxysmal ventricular standstill is made, the management should be immediate with either permanent pacemaker implantation or an alternative. In their case of paroxysmal ventricular Standstill, Ehsani-Nia et al. described a 68-year-old woman with altered mental status who underwent cardiopulmonary resuscitation, transcutaneous, and then transvenous pacing, and finally the implantation of a permanent pacemaker to survive; the diagnosis was also fortuitous [8]. Unfortunately, in our case, the patient refused the management plan due to cultural beliefs and decided to seek an alternative means to solve his condition. The patient was subsequently lost to follow-up.

Conclusion     

This case is the first report of paroxysmal ventricular standstill in Cameroon. Paroxysmal ventricular standstill is commonly difficult to diagnose and unfortunately sometimes life-threatening. Clinicians in resource-limited countries need to request further evaluation like Holter-ECG or Telemetry when investigating for syncope in a patient without obvious cause. Through this report, we aimed to raise awareness of this rare cause of Stokes-Adam attacks and its common differential: Ictal asystole.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Patient management: Armel Djomou Ngongang. Data collection: Armel Djomou Ngongang, Etienne verlain Fouedjio Kafack, Xavier Kuelang Kengni. Manuscript drafting: Armel Djomou Ngongang, Etienne Verlain Fouedjio Kafack. Manuscript revision and approval of the final version: Armel Djomou Ngongang, Etienne Verlain Fouedjio Kafack, Xavier Kuelang Kengni, Christian Ngongang Ouankou, Christelle Yopa Kenmegni, Félicité Kamdem. All the authors have read and agreed to the final manuscript.

Figures     

Figure 1: period of asystole showed in red color

Figure 2: prolong P-waves without ventricular activity after the last ventricular activity (in green)

References