Angry Purkinje Syndrome: A Review of Short-Coupled Polymorphic Ventricular Tachycardia with Quinidine Treatment

BACKGROUND: Polymorphic ventricular tachycardia (VT) mediated by short-coupled premature ventricular complexes in patients with recent myocardial infarction is termed 'Angry Purkinje Syndrome'. These arrhythmias are typically refractory to conventional antiarrhythmic therapy but may respond to quinidine. METHODS & RESULTS: We present a case series of patients with short-coupled polymorphic VT occurring 2-8 days after acute myocardial infarction and coronary revascularisation. All three patients had recurrent polymorphic VT episodes that were consistently initiated by ventricular ectopy with a short coupling interval of 360 milliseconds. All three patients experienced arrhythmic storms requiring multiple cardioversions and were refractory to amiodarone, procainamide, lignocaine, and isoprenaline. Quinidine led to sustained suppression of ventricular arrhythmias, with marked reduction in premature ventricular contraction burden within 24 hours. Two patients were successfully extubated 4 days after arrest, and the third was decannulated from extracorporeal membrane oxygenation 4 days after quinidine initiation. CONCLUSIONS: 'Angry Purkinje Syndrome' is an uncommon but important cause of polymorphic VT in patients with coronary disease not related to acute myocardial ischaemia. Quinidine appears to provide effective suppression of Purkinje-mediated polymorphic VT and may represent an important therapeutic option in this setting.