We report a case of a 56-year-old man with electrical storm, who exhibited simultaneous occurrence of augmented QRS notching and macroscopic T-wave alternans (TWA) preceding ventricular fibrillation (VF).

The patient was found to be in VF in his bed (02:00 am). He was on medication for coronary artery disease but had no history of myocardial infarction. An admission electrocardiogram was unremarkable except for QRS slurring in the inferior leads. Immediate coronary angiogram revealed no source of acute ischaemia. Within the first 4 h of admission, however, he developed two episodes of VF, which was not preceded by chest pain. Lead II telemetry strip obtained during the episode is shown (Figure). Early repolarization was not evident at baseline (black arrows). QRS notching (red arrows) and macroscopic TWA (red...

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