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A holiday for the heart

A 16 years old male presents to the pediatric emergency department for palpitations. Symptoms appeared suddenly 12 hours ago. No dizziness, no vomiting, no syncope. No prior medications and no concerning prior diseases.


Physical exam: BMI 28, arrhythmic pulse, clear heart sounds, pale skin, BP 123/64 mmHg.


ECG:

Leg: 25mm/sec, HR 100-110 bpm, arrhythmic, no discernible P waves. Atrial fibrillation (AF).



There is irregular QRS complexes without clearly discernible P waves. Patient has tachycardia. The diagnosis of atrial fibrillation was made.


Now, for further treatment we considered electrical cardioversion since onset of symptoms was 12 hours ago and transthoracic echo showed no signs of thrombi (<48h no transesophageal echo mandatory).

Synchronized cardioversion was performed using 100J (sedation using propofol).


Leg: at the beginning there is AF, followed by the applied electrical cardioversion (bold vertical line). Following CV there is sinus rhythm (upright P waves in I,II,aVF prior to every QRS).


Diagnostic workup did not reveal any pathological causes in this patient. However, retaking history, the patient announced he had been out drinking quite a lot on the day before his symptoms appeared. In adolescents there is a rather rare form of AF attributed to alcohol consumption, known as Holiday Heart Syndrome. We hypothesized this to be the case in our patient. Good news is, this condition can usually be controlled rather easily by alcohol restriction. "Bad news" would be that Holiday Heart Syndrome may reappear consuming not loads of alcohol, but even small amounts. Therefore we recommended strict abstinence.

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