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A red herring electrocardiogram

Published:August 12, 2022DOI:https://doi.org/10.1016/j.ejim.2022.08.003

      Keywords

      Case description

      A gentleman in his 50s presented with atypical chest pain for the last 3 months. He had no prior comorbidities. Cardiovascular system examination was unremarkable. Baseline electrocardiogram is shown in Fig. 1A. The primary care physician labelled the electrocardiogram as ST-segment elevation myocardial infarction and advised immediate coronary angiography and intervention. The electrocardiogram was reviewed by the cardiology team, and a repeat electrocardiogram was advised, shown in Fig. 1B.
      Fig 1
      Fig. 1A. Initial ECG. It shows a sinus rhythm with apparent ST-segment elevation in leads I, aVL and reciprocal ST-segment depression in leads III, aVF. B. Repeat ECG. It shows a sinus rhythm with complete resolution of the ST-segment deviations noted in the first ECG.
      What is the diagnosis suggested by these electrocardiograms?

      Discussion

      Diagnosis: Pulse tapping artifact

      Electrocardiogram in Fig. 1A shows a sinus rhythm with a heart rate of 110 beats per minute. The electrocardiogram was initially misread as ST elevations in leads I, aVL and ST depression in leads III, aVF. On closer inspection, the ST segment is actually isoelectric in these leads, with bizzare appearance of the T waves. Such bizzare appearance of the T waves suggests the presence of an artifact. There is a constant delay between the onset of QRS complexes and the artifact, which suggests that the artifact is synchronous with cardiac cycle. This phenomenon occurs due to tapping of arterial pulse on the electrocardiogram electrodes, which is known as arterial pulse tapping artifact.
      The repeat electrocardiogram in Fig. 1B was taken such that the electrode was not directly on the pulse, showed disappearance of the artifact. The patient did not have any acute chest discomfort and echocardiography did not show any wall motion abnormality.
      Such electrocardiogram changes were first reported by Ozhan et al [
      • Ozhan H.
      • Akdemir R.
      • Duran S.
      • et al.
      Transient silent ischemia after percutaneous transluminal coronary angioplasty manifested with a bizarre electrocardiogram.
      ], which were initially attributed to silent ischemia. However, it was Aslanger and Bjerregaard [
      • Aslanger E.
      • Bjerregaard P.
      Mystery of “bizarre electrocardiogram” solved.
      ] who described the mechanism of these electrocardiographic changes. Pulse tapping artifacts are usually reported in patients with high volume pulses. It is essential of recognize such intimidating artifacts to avoid unnecessary interventions.

      Disclosures

      None.

      Patient consent for publication

      Obtained

      Declaration of Competing Interest

      There are no conflicts of interest.

      Acknowledgements

      None.

      References

        • Ozhan H.
        • Akdemir R.
        • Duran S.
        • et al.
        Transient silent ischemia after percutaneous transluminal coronary angioplasty manifested with a bizarre electrocardiogram.
        J Electrocardiol. 2005; 38: 206-209
        • Aslanger E.
        • Bjerregaard P.
        Mystery of “bizarre electrocardiogram” solved.
        J Electrocardiol. 2011; 44: 810-811