Short QT Syndrome With Synonymous RYR2 Variant

BACKGROUND: Short QT syndrome (SQTS) is a rare inherited channelopathy associated with malignant ventricular arrhythmias and sudden cardiac death. CASE SUMMARY: A 48-year-old man presented with syncope without prodromes. Electrocardiogram showed a QTc of 320 ms and family history included sudden death at 16 years. Cardiac evaluation was unremarkable, while tilt testing suggested vasovagal syncope. Genetic testing identified a synonymous RYR2 variant of uncertain significance. Despite a probable SQTS diagnosis, the absence of ventricular arrhythmias supported an intermediate-risk profile. An implantable loop recorder was implanted. At 12 months, no arrhythmic events were detected. DISCUSSION: SQTS risk stratification remains challenging, particularly in the absence of pathogenic variants. This case suggests that noncanonical genetic findings may expand the genetic spectrum of SQTS, while requiring cautious interpretation. TAKE-HOME MESSAGES: Risk stratification in SQTS should integrate clinical context. In selected intermediate-risk patients, conservative management with longitudinal monitoring may be appropriate.