A 75 year-old man with a history of exercise induced throat tightness intermittently associated with near syncope is admitted to the cardiology teaching service.  His baseline ECG was normal but because of a mildly elevated Troponin level he was admitted as a non-ST elevation myocardial infarction.  He underwent persantine myocardial perfusion imaging.  The baseline ECG is shown below.

• Sinus rhythm, rate 73/min
• Left axis deviation
• Incomplete Right Bundle Branch Block (iRBBB)

During infusion of persantine, the following ECG is noted.

One minute later, the following ECG is recorded.

• Sinus rhythm, rate 70/min
• Short runs of polymorphic ventricular tachycardia
• ST changes are slightly improved compared to previous but not back to baseline

Comment: This case highlights an atypical presentation of coronary artery disease with ischemia induced polymorphic ventricular tachycardia which likely resulted in the patients clinical symptoms of near-syncope.  He underwent coronary angiography which revealed severe stenosis of the right coronary artery and underwent PCI with stenting.  He remained symptom free at time of follow up 3 years later.