Pseudo–Ventricular Tachycardia Mimicking Malignant Arrhythmia in a Patient with Rapid Atrial Fibrillation

Abstract

Artifacts can simulate arrhythmias such as atrial flutter, atrial fibrillation, and ventricular tachycardia. A case of pseudo-ventricular tachycardia is outlined in a patient with newly diagnosed atrial fibrillation, which made the diagnosis a special challenge. Characteristic signs of pseudo-ventricular tachycardia are described. This case reinforces the importance of recognizing artifacts to avoid unnecessary interventions, especially in the telemetry and critical care units. (American Journal of Critical Care. 2014;23:270-272) A 51-year-old man with a history of mitral valve endocarditis, mitral valve prolapse and regurgitation, hypertension, type 2 diabetes mellitus, and alcohol abuse came to the emergency department with nausea, vomiting, and vague abdominal pain after a binge of alcohol the preceding night. Vital signs included a heart rate of 132 beats/min, blood pressure of 125/96 mm Hg, respiratory rate of 18/min, and body temperature of 36.7ºC. Physical examination was significant for irregular heart sounds with pansystolic murmur best heard at the apex with radiation to the left axilla. His abdomen was tender with absent peritoneal signs. Electrocardiography showed atrial fibrillation with rapid ventricular response (130/min). The patient was admitted to the general internal medicine service for telemetry monitoring and management of his newly diagnosed atrial fibrillation.While being assessed by the medicine team in the emergency department, the patient had an 11-second run of an apparent irregular wide-complex tachycardia at 250/min with variable morphology (Figure, part A). The patient was asymptomatic and his blood pressure remained stable. The electrophysiology service was consulted urgently. Does this patient have ventricular tachycardia? Clinical CourseThe patient started treatment with bisoprolol 5 mg daily for rate control of atrial fibrillation and rivaroxaban 20 mg daily for stroke prophylaxis. After a close look at the tracings, the consulting Cases of Note features peer-reviewed case reports and case series that document clinically relevant findings from critical and high acuity care environments. Cases that illuminate a clinical diagnosis or a management issue in the treatment of critically and acutely ill patients and include discussion of the patient's experience with the illness or intervention are encouraged. Proposals for future Cases of Note articles may be e-mailed to ajcc@aacn.org.

The Quest for Quality Electrocardiographic Recording

“…This greatly helps to minimize the appearance of artifacts that can sometimes cause significant diagnostic errors. 6…”