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A 66-year-old woman was referred for evaluation of an abnormal electrocardiogram (ECG), functional class II exertional dyspnea, and intermittent paroxysms of palpitations in the absence of chest pain. An ECG 3 years earlier was normal (Figure 1A). The review of systems was noncontributory.

The past medical history included hepatitis C complicated by hepatocellular carcinoma, with subsequent deceased-donor liver transplant 3 years prior, hypertension, type 2 diabetes mellitus, chronic kidney disease stage 3, active tobacco use, and hypothyroidism. A dobutamine stress echocardiogram performed prior to liver transplant had demonstrated normal left ventricular ejection fraction (67%), normal right ventricular function, no valvular abnormalities, and no evidence of ischemia during peak stress.