5th International Conference on Heart and Cardiovascular Diseases

Pawan Kumar, a GMC-registered doctor working in the NHS in Birmingham, UK. I have clinical experience in Acute and General Internal Medicine, with interests in acute care, clinical research, quality improvement and medical education. I have been involved in clinical and academic projects and am passionate about evidence-based medicine, continuous professional development and sharing knowledge through medical conferences and professional collaboration. Me along with my colleague Dr Kanchan Kanchan Wanted to present this case as poster Presentation, she is also GMC registered doctor working at NHS Trust in Birmingham UK.

Statement of the Problem:

Torsade's de Pointes (TdP) is a rare but potentially fatal polymorphic ventricular tachycardia, typically associated with QT interval prolongation. However, TdP with a normal QT interval is uncommon and may present as a seizure-like episode, creating significant diagnostic challenges. This educational case highlights the importance of recognising cardiac arrhythmias as an important differential diagnosis in patients presenting with unexplained seizure-like activity.

Methodology and findings:

We present a educational case of a 40-year-old man admitted following a witnessed seizure-like episode characterised by generalized tonic-clonic movements without tongue biting, urinary incontinence, or post-ictal confusion. Electrocardiography demonstrated short-coupled premature ventricular complexes with an R-on-T phenomenon despite a normal QTc of 430 ms. Continuous cardiac monitoring revealed recurrent non-sustained TdP. Coronary angiography identified significant left anterior descending artery disease, and cardiac magnetic resonance imaging confirmed ischaemic myocardial injury with moderately impaired left ventricular systolic function (ejection fraction 38%).

Management:

The patient required immediate treatment with intravenous antiarrhythmic therapy, repeated direct-current cardioversion, and temporary overdrive pacing to suppress recurrent ventricular arrhythmias. Percutaneous coronary intervention with drug-eluting stent implantation to the left anterior descending artery was successfully performed. During admission, the patient developed ventricular fibrillation requiring advanced life support and successful resuscitation. A subcutaneous implantable cardioverter-defibrillator was recommended for secondary prevention.

Conclusion & Significance:

This case demonstrates that TdP should be considered in the differential diagnosis of seizure-like episodes, even in the absence of QT prolongation. Recognition of the R-on-T phenomenon, short-coupled premature ventricular complexes, and underlying myocardial ischaemia is essential for timely diagnosis and life-saving intervention. This published educational case provides valuable learning points for emergency physicians, cardiologists, and acute medical teams regarding the recognition and multidisciplinary management of this rare arrhythmic emergency.