Can the electrical heart system betray severe underlying coronary artery disease? When cardiac arrhythmias speak loud and clear

Introduction:

Coronary artery disease remains a leading cause of morbidity and mortality worldwide, driven by atherosclerotic plaque formation that narrows or blocks coronary arteries, manifesting across a spectrum, from asymptomatic stages to life-threatening acute coronary syndromes, including myocardial infarction. Can it be identified by understanding and recognizing heart arrythmias, such as premature ventricular or atrial complexes or sinus bradycardia?

Methods:

We present the case of a 79-years-old male with important cardiovascular comorbidities who presented to our clinic for shortness of breath on exertion and fatigue during low intensity efforts. Upon closer examination using indispensable tools such as ECG and ECG Holter monitoring, supraventricular ectopic beats (atrial bigeminy from the right superior pulmonary vein, predominantly) and non-sustained ventricular tachycardia on a bradycardic rhythm were diagnosed, in spite of maximal and optimal anti-ischemic treatment. In addition, a mild reduced left ventricular ejection fraction was assessed. The location of ventricular arrhythmias points to the right coronary artery. By correlating clinical judgement with these data, severe underlying coronary artery disease was suspected and subsequently confirmed by coronary angiography, which showed triple vessels disease with a 50% stenosis of the left main due to the chronic lesions. The following question was asked: should the patient benefit from PCI or CABG?

Conclusions:

Although heart ischemia can embody a large spectrum of clinical (excluding angina) and paraclinical manifestations, heart arrhythmias often accompany or expose underlying coronary artery disease. It is fundamental for the clinician to understand the substrate and the site of arrhythmias, in order to appropriately asses and solve the medical puzzle.