His hernia surgery is scheduled but these results of a routine pre-op ECG could change plans. What's your ECG read?
A 77-year-old man with hypertension but otherwise without known cardiac comorbidities presents to your clinic for routine follow-up. He is doing well and is asymptomatic, although he is undergoing evaluation by a neurologist for possible Parkinson’s disease. He relates that he has an upcoming hernia surgery. You perform an ECG for preoperative evaluation, shown in Figure 1:
Based on what you see here, what is the next step in the management of this patient (more than one answer may be correct)?
A. Start anticoagulation
B. Refer for direct current cardioversion
C. Refer for ablation
D. Delay surgery
E. No intervention needed; proceed with surgery
Answer and discussion, next page>>
Answer: E. No intervention needed; proceed with surgery
Motion artifact due to tremor or shivering can obscure the waveforms of the ECG or simulate pathology. The patient in this case had Parkinson’s disease with a bilateral resting hand tremor that occurred during obtaining his ECG. The undulating baseline in this ECG gives the appearance of atrial flutter waves. On closer inspection, there are visible P waves on lead II (circled in Figure 2).
Repeat patient ECG clearly shows sinus rhythm with the first part of the strip showing the same “pseudo-atrial flutter” waves from tremor most apparent on lead I (Figure 3).
In addition to tremor, motion artifact can also be seen with fever, hypothermia, and cardiopulmonary resuscitation. Telemetry and Holter monitoring not infrequently will misdiagnose artifact from a patient’s rapid arm movement with teeth and/or hair brushing as malignant ventricular arrhythmias.
For additional examples of artifact mimicking pathologic rhythms:
Mascitelli L, Pezzetta F. Case report: differentiating artifact from true ventricular tachycardia [letters to the editor]. Am Fam Physician. 2006 Sep 15;74(6):921.
Patel S. Electrocardiographic artifact mimicking ventricular tachycardia durig high-frequency oscillatory ventillation: a case report. Am J Crit Care. 2006;15:310-311
Matthias AT, Indrakumar J. Electrocardiogram artifact caused by rigors mimicking narrow complex tachycardia: a case report. BMC Res Notes. 2014; 7: 80.