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1 Credit CME

A 65-year-old man who had been treated for hypertension for the past 10 years presented with increasing fatigue, dizziness, and palpitations. He did not have chest pain or any other symptoms. An electrocardiogram (ECG) was obtained (Figure 1).

Atrial fibrillation

B. Review the ECG for features of atrial fibrillation

The key to the correct diagnosis in this case is the absence of P waves, irregularly irregular R-R intervals, and fibrillary (f) waves on the ECG tracing. Careful analysis of the tracing is required to establish these features of atrial fibrillation (AF). Other dysrhythmias that have a similar appearance include frequent atrial ectopic beats, wandering atrial pacemaker, multifocal atrial tachycardia, and atrial flutter with varying AV block. These conditions may be distinguished from AF on the ECG by the fact that organized atrial activity would be present and denoted by the presence of distinct P waves, which are not seen on this tracing.

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Atrial fibrillation

B. Review the ECG for features of atrial fibrillation

The key to the correct diagnosis in this case is the absence of P waves, irregularly irregular R-R intervals, and fibrillary (f) waves on the ECG tracing. Careful analysis of the tracing is required to establish these features of atrial fibrillation (AF). Other dysrhythmias that have a similar appearance include frequent atrial ectopic beats, wandering atrial pacemaker, multifocal atrial tachycardia, and atrial flutter with varying AV block. These conditions may be distinguished from AF on the ECG by the fact that organized atrial activity would be present and denoted by the presence of distinct P waves, which are not seen on this tracing.

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Article Information

Corresponding Author: Elsayed Z. Soliman, MD, MSc, MS, Epidemiological Cardiology Research Center (EPICARE), Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157 (esoliman@wakehealth.edu).

Conflict of Interest Disclosures: None reported.

References
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Fung  E, Järvelin  MR, Doshi  RN,  et al.  Electrocardiographic patch devices and contemporary wireless cardiac monitoring.  Front Physiol. 2015;6:149. doi:10.3389/fphys.2015.00149PubMedGoogle ScholarCrossref
3.
Bogun  F, Anh  D, Kalahasty  G,  et al.  Misdiagnosis of atrial fibrillation and its clinical consequences.  Am J Med. 2004;117(9):636-642. doi:10.1016/j.amjmed.2004.06.024PubMedGoogle ScholarCrossref
4.
Davidenko  JM, Snyder  LS.  Causes of errors in the electrocardiographic diagnosis of atrial fibrillation by physicians.  J Electrocardiol. 2007;40(5):450-456. doi:10.1016/j.jelectrocard.2007.01.003PubMedGoogle ScholarCrossref
5.
Cheniti  G, Vlachos  K, Pambrun  T,  et al.  Atrial fibrillation mechanisms and implications for catheter ablation.  Front Physiol. 2018;9:1458. doi:10.3389/fphys.2018.01458PubMedGoogle ScholarCrossref
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Goldberger  AL, Goldberger  ZD, Shvilkin  A.  Goldberger’s Clinical Electrocardiography. 9th ed. Amsterdam: Elsevier; 2018.
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Gutierrez  C, Blanchard  DG.  Atrial fibrillation: diagnosis and treatment.  Am Fam Physician. 2011;83(1):61-68.PubMedGoogle Scholar
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