We report the case of a patient in whom dramatic T wave alternans with brief bouts of torsades de pointes and QT prolongation occurred in association with intravenously administered pentamidine. This ECG marker of a potentially fatal side effect, although uncommon, should be looked for in patients requiring the use of this drug.

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A 49-year-old man who had undergone coronary artery bypass grafting 16 months earlier presented with complaints of increasing angina pectoris. Initial angiography of the left coronary artery showed that contrast dye went retrograde up the left internal mammary artery (LIMA) and into the subclavian artery (Figure, A). Competitive flow was observed in the chest wall branches of the LIMA. Angiography demonstrated a severe obstruction of the left subclavian artery (Figure, B) with poor opacification of the artery distal to the stenosis and minimal appearance of contrast dye in the vertebral artery or LIMA. After stent placement (Figure, C), the subclavian artery, vertebral artery, and LIMA were all opacified by antegrade flow. This case demonstrates angiographic evidence of flow from the coronary system into the subclavian artery and supports prior reports of the existence of coronary-subclavian steal syndrome in patients with LIMA grafts and subclavian disease.A, Angiography of the left coronary artery and LIMA in a right anterior oblique cranial projection. The figure is a composite of 2 images obtained during the same injection. The arrow points to the subclavian artery. B, Angiography of the left subclavian artery in an anterior-posterior projection. C, Angiography of the left subclavian artery in an anterior-posterior projection after stent placement. Vert indicates vertebral artery.

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