Syncope as a manifestation of subclavian steal syndrome in an elderly patient with congestive heart failure

An 81-year-old male was admitted because of syncope. Loss of consciousness occurred during exercise with the right upper extremity. He was a smoker and had history of congestive heart failure with reduced ejection fraction (25%), hypertension, dyslipidemia, bilateral carotid atherosclerosis and brainstem infarction (2 years before a magnetic resonance documented bilateral pontine lesions). He experienced two episodes of syncope in the prior 3 years, provoked by the physical exercise with the right arm. His medications included ticlopidine, beta-blocker, angiotensin receptor blocker and statin. The 12-lead electrocardiogram revealed a complete left brundle block without abnormalities in the atrioventricular conduction. There were no physical or biochemical signs of acute ischemic heart disease. Laboratory tests showed no abnormalities in blood count, renal and hepatic function. On physical examination volume of right brachial, ulnar and radial pulses were significantly reduced. Blood pressure was measured in both arms and was 100/60 mmHg in the left one and 80/60 mmHg in the right one. Carotid and vertebral bruits were absent.