A 33-year-old man presented to the emergency department (ED) following two unresponsive episodes in bed that night. The patient's wife described episodes of loss of consciousness and agonal breathing lasting approx20-30 seconds(s). He reported feeling short of breath and disorientated but denied chest pain. Past medical history was significant only for achalasia which had been treated years previously with a Heller's myotomy. There was no significant family history, and he took no regular medications. Physical examination was unremarkable. Electrocardiogram demonstrated normal sinus rhythm with ST-elevation and T-wave inversion in aVR and V1-V3. Initial troponin T was elevated at 55ng/l (normal range: 0-14 ng/l). Chest X-ray was normal, and N-terminal pro-brain natriuretic peptide (NT-proBNP) was elevated at 1511 pg/ml (normal range: 0-400 pg/ ml). Bedside echocardiography showed significant biventricular hypertrophy with impaired biventricular systolic function (Figure 1B). Within hours of ED arrival, the patient suffered a cardiac arrest. Telemetry showed ventricular standstill lasting 30 s (Figure 1A).
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