Author: Michael Boutros, BS
Co Author #1: Kirin Cromer, BS
Co Author #2: Kristopher Paultre, MD
Senior Editor: Kristine Karlson, MD, FAMSSM
Editor: Jeffrey Kepple, MD

Patient Presentation:
A 20-year-old female collegiate rower presented to the sports medicine clinic for evaluation of palpitations and paroxysmal tachyarrhythmia that had progressively limited her athletic training.

History:
The patient reported intermittent, abrupt-onset palpitations beginning at approximately age 12 to 13, which self-terminated with cough or rest. She had never sought evaluation prior to the index episode. The patient endorsed she had been told in the past she had a remote history of a patent foramen ovale; no known structural heart disease was present. In the summer, during off-season training, she developed a three-hour episode of rapid heartbeat recorded at 170 to 205 beats per minute on her wearable device following caffeine intake, associated with lightheadedness and near-exhaustion. Symptoms resolved with a cold-stimulus vagal maneuver. She denied syncope, chest pain, stimulant use, and family history of sudden cardiac death. She was seen by a local cardiologist, who reviewed wearable data showing a peak of 230 beats per minute and suspected paroxysmal supraventricular tachycardia.
Case Photo #1
The home cardiologist prescribed metoprolol succinate 25 mg as needed, which she never used because she did not experience additional episodes of the same severity. In the months that followed, shorter but increasingly frequent episodes continued to limit training despite caffeine avoidance, prompting further evaluation at our institution once she returned to campus for the fall semester.

Physical Exam:
Well-appearing athletic female in no acute distress. Blood pressure 122/76 seated and 116/74 standing; heart rate and respirations within normal limits. Cardiovascular exam demonstrated regular rate and rhythm, normal S1 and S2, and no murmurs, rubs, clicks, lifts, heaves, or thrills. The remainder of the examination was unremarkable. Paroxysmal arrhythmia was not captured at rest.

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