Let's consider another case. This is a 23-year-old woman with a history of palpitations and near syncope when running, who had been treated with Nadelol 40 milligrams daily. She had a sister who died suddenly at age 16 during soccer practice. Her own prior evaluation revealed the ECG shown in figure 8.1 below and a Holter monitor around the same time revealed 230 PBCs in a 24-hour period. On exercise treadmill test, she exercised for 12 minutes to a peak heart rate of 190 beats per minute with an ECG and early recovery shown in figure 8.2. Post-mortem genetic testing in her sister revealed a pathologic ryanodine receptor mutation as well as a variant of uncertain significance in the ryanodine receptor as well. She's now pregnant. She's entering her third trimester. She has more frequent palpitations at rest, but has not had syncope or near syncope, and a representative monitor strip is shown below. Which of the following is most appropriate? Increase the dose of Nadelol and monitor, add flecainide and monitor, add a calcium channel blocker and provide a wearable defibrillator, and implant or implant an SICD. Let me give you some time to consider the choices.

ryanodine receptor mutation

palpitations

pregnancy

subcutaneous implantable cardioverter-defibrillator

cardiac management