BMJ Case Reports 2018; doi:10.1136/bcr-2018-225515
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T-wave alternans: a harbinger for malignant ventricular arrhythmias

  1. Muralikrishnan Harikrishnan1
  1. 1Department of Internal Medicine, Medical College Hospital, Thiruvananthapuram, Kerala, India
  2. 2Intenal Medicine, Medical College Hospital, Trivandrum, Kerala, India
  1. Correspondence to Professor Chandrasekharan Rajasekharan, drcrajasekharan{at}
  • Accepted 21 June 2018
  • Published 12 July 2018


A 50-year-old male chronic alcoholic presented to our emergency department with seizures and loss of consciousness after an alcoholic binge. He had no other significant medical history and was not on any regular medications. On examination, his pulse was 90 beats/min and his blood pressure was 80/60 mm Hg. His resting ECG showed sinus rhythm with QT prolongation. His serum sodium was 133 mmol/dL, potassium was 3.5 mmol/dL, magnesium was 1.4 mmol/dL and calcium was 6.6 mg/dL. The ECG demonstrated wide QRS tachycardia with a heart rate of approximately 200 beats/min and mild irregularity and morphology suggestive of polymorphic ventricular tachycardia initiated by a ventricular premature contraction falling on the terminal part of the T wave of the preceding sinus beat (figure 1A, black arrows). The postelectroversion tracing showed sinus rhythm at a rate of 55 beats/min, with alternating small, narrow (figure 1B, red arrows) and broad deep T-wave inversions (figure 1B, black arrows) with a measured QT interval of 800 ms …

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