A 72-year-old man was admitted to the MSICU after vascular surgery.  Post extubation, he developed the rhythm noted below:

• Sinus Rhythm with premature ventricular complexes followed by onset of Polymorphic Ventricular Tachycardia and Ventricular Fibrillation

Comment: In sinus rhythm, with the two leads shown, the patient has a normal QT interval and no obvious ST segment changes.  However, in the setting of polymorphic ventricular tachycardia which occurs in the setting of a normal QT interval and is initiated by a relatively close coupled (less than 400ms) premature ventricular complex, the most likely cause is coronary ischemia.  This patient underwent coronary angiography and was found to have a very severe stenosis of the circumflex artery which receive PCI with a drug eluting stent.