Electrocardiographic artifact potentially misleading to the wrong management

Abstract

Atrial flutter (AF) is the second most common supraventricular tachyarrhythmia following atrial fibrillation. We present an interesting case of a diagnostic challenge manifested as an electrocardiogram (ECG) recording mimicking AF in a patient with Parkinson's disease (PD). A 72-year-old African-American female with history of PD presented to our Emergency Department with a one day history of chest pain. Her vital signs were within normal limits. Physical exam was remarkable for bilateral resting hand tremors at a frequency of 6-8 hertz and mild cogwheel rigidity in both upper extremities. Initial ECG was interpreted as AF prompting admission. After careful review of her ECG by a cardiologist, several features such as, sharply contoured upright p waves in all leads, different flutter wave morphologies in the same leads, more prominence of "pseudo-flutter" waves in the limb leads compared to the precordial leads, and return to isoelectric baseline after sharp peaked p waves, questioned the diagnosis of AF. A repeat 12 lead ECG clearly demonstrated normal sinus rhythm, and the patient remained completely asymptomatic throughout the stay. A 48-hour Holter monitoring in the clinic later confirmed consistent sinus rhythm with no evidence of any arrhythmias Tremor induced artifacts can be mistaken for arrhythmias. Correct and accurate diagnosis is critically important, in order to avoid wrong treatment and unnecessary interventions. Our case illustrates the importance of recognizing artifact related ECG changes to prevent unnecessary treatment and hospital admissions.

Pseudo–Ventricular Tachycardia, Pseudo–Atrial Fibrillation, and Pseudo–Atrial Flutter in a Patient With Parkinson Disease

“…3 When there is a suspicion of a wide-QRS tachycardia, we can look for the native rhythm (R waves) marching through the artifact rhythm, which will ultimately help in recognizing whether it is a true ventricular tachycardia or pseudo-arrythmia. [3][4][5] Interestingly, we can see the baseline artifact in the telemetry strip (Figure 3A) continue to increase in amplitude until the full-blown artifact occurs (Figure 3B). This is likely a result of the Parkinsonian tremor increasing in amplitude and intensity.…”

“…Being able to recognize that these are not true arrhythmias is crucial in ensuring that patients are not condemned to unnecessary diagnostic and therapeutic interventions. [1][2][3][4][5] Take-Home Points…”

Identifying and troubleshooting low-frequency artifacts mimicking atrial flutter caused by deep brain stimulator

“…Lack of relationship between flutter waves and QRS complexes would suggest complete heart J o u r n a l P r e -p r o o f block 2 ; but the PR interval was normal during sinus rhythm, and no heart block events were otherwise recorded. Parkinsonian tremor has been implicated in causing artifact due to baseline undulation mimicking atrial and ventricular tachy-arrhythmias [3][4][5] . Hwang et al found that 89/100 patients with a Parkinson tremor at rest had ECG artifacts.…”

Tremor mimicking ventricular tachycardia (VT): Treat your patients, not the ECG

“…An electrocardiogram (ECG) is one of an important bedside investigation technique used for finding abnormalities and to help diagnose cardiac diseases [1]. Fine skills are needed to match the symptoms of the patient with their ECG findings to make a diagnosis in heart disease, because artefacts are also common findings in an ECG at in-patient setting which sometimes can lead to misreading as tachyarrhythmias [2].…”