Page 84 - JSOM Summer 2024

Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)
in a Special Operations Soldier

A Case Report

1
Kyler C. Osborne, MD *; Andrew Wenthe, SOCM (A.W.) ;
2
3
Megan Mahowald, MD ; Rachel E. Bridwell, MD 4

ABSTRACT
Special Operations Servicemembers presenting with palpi- ventricular arrhythmias provoked from exercise. In the gen-
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tations, pre-syncope, or exertional syncope during rigorous eral population, ARVC accounts for up to 20% of all SCDs,
physical training are often experiencing a benign condition; especially in healthy individuals and athletes under the age of
however, life-threatening etiologies should be considered. We 35 years. Notably, high-intensity exercise in otherwise healthy
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describe a 43-year-old Special Operator who presented to and asymptomatic individuals with ARVC gene mutations can
his medics during selection physical assessment testing with lead to earlier disease manifestation with increased incidence
palpitations and lightheadedness, with a subsequent workup of arrhythmias. Though ARVC is a rare diagnosis among the
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revealing arrhythmogenic right ventricular cardiomyopathy general population and U.S. military members alike, it is a
(ARVC). His initial electrocardiogram was unremarkable with- potentially life-threatening condition. Therefore, palpitations
out characteristic ARVC changes. Outpatient evaluation with or other pre-syncopal episodes in Special Operations Service-
ambulatory cardiac monitoring recorded numerous episodes of members, even in the setting of minimal or intense physical
non- sustained ventricular tachycardia. Transthoracic echocar- activity, must be investigated by Special Operations providers.
diography demonstrated findings concerning for ARVC, with
subsequent cardiac MRI confirming the diagnosis via the 2020 Case Presentation
Padua criteria. Management includes activity modification,
class III antiarrhythmic medications, and possible placement A 43-year-old active-duty male Special Operations Soldier
of an implantable cardioverter defibrillator to prevent sudden presented to his Battalion Aid Station (BAS) at the recommen-
cardiac death. This case demonstrates the importance of main- dation of his medics for palpitations that occurred during se-
taining high clinical suspicion for rare diagnoses that present lection physical assessment testing. The patient was seen by
with exertional palpitations, such as arrhythmogenic right ven- the battalion surgeon and physician assistant on his initial
tricular cardiomyopathy, in even our fittest Special Operators. evaluation. Despite resolution of his palpitations, he contin-
ued to experience intermittent lightheadedness. His vital signs
Keywords: ARVC; arrhythmia; arrhythmogenic cardiomyopa- were remarkable for a heart rate of 92 beats per minute, blood
thy; sudden cardiac death; ventricular tachycardia pressure of 126/68mmHg, respiratory rate of 20 breaths per
minute, SpO of 98% on room air, and an oral temperature
2
of 36.9°C. Physical examination was unremarkable and with-
out evidence of cardiopulmonary abnormalities. His medical
Introduction
history was remarkable for post-traumatic stress disorder
Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a and anxiety, though he was not on any psychoactive or QT-
rare inherited cardiomyopathy that can lead to life- threatening prolonging medications. His review of systems was notable for
arrhythmias and sudden cardiac death (SCD). More commonly previous episodes of non-exertional dizziness, though he had
occurring in males under the age of 35, ARVC affects roughly not sought any prior medical care for them. He denied history
1 in 5,000 individuals. In a 10-year review of autopsy data of exertional syncopal or near-syncopal episodes. He denied
1
from the U.S. Department of Defense, 715 out of 902 cases alcohol or pre-workout use but said that he drinks five cups of
of SCD were due to underlying cardiac conditions, of which coffee per day. He denied any family history of known heart
10 cases of ARVC were identified. In an additional study disease, cardiomyopathy, or SCD. An initial 12-lead electrocar-
2
from the U.S. Military Health System performed from 2005 diogram (ECG) revealed sinus bradycardia with normal inter-
to 2010, 3 cases of ARVC were found among 200 cases of vals and non-specific T-wave inversion in V1 and an equivocal
exertional SCD. The majority of these exertional SCDs were T-wave inversion in V2 (Figure 1). He was referred for 7 days
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during organized physical training or mandatory physical fit- of ambulatory cardiac monitoring, which recorded 11 runs of
ness tests. Based on these data, prevention of sudden death in non-sustained ventricular tachycardia (VT) and several inci-
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Servicemembers aged younger than 35 years should focus on dences of coupled premature atrial contractions (PACs) as well
investigations of primary arrhythmias. Patients with ARVC as coupled premature ventricular contractions (PVCs). The pa-
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frequently present with palpitations, dyspnea, or syncope from tient did not report or document any episodes of palpitations
*Correspondence to kyler.c.osborne.mil@health.mil
1 CPT Kyler C. Osborne is a resident physician affiliated with the Department of Emergency Medicine, Madigan Army Medical Center, Joint
Base Lewis–McChord, WA. SO1 Andrew Wenthe is an Enlisted to Medical Degree Preparatory Program (EMDP2) student affiliated with the
2
3
Uniformed Services University of the Health Sciences, Bethesda, MD. MAJ Megan Mahowald is a physician affiliated with the 75th Ranger
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Regiment, Fort Moore, GA. MAJ Rachel E. Bridwell is a physician affiliated with the Army Special Operations Aviation Command, Fort Liberty,
NC, and Uniformed Services University of the Health Sciences, Bethesda, MD.
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