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An Important Cause of Wide Complex Tachycardia

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To identify the key insights or developments described in this article
1 Credit CME

A man in his 60s was admitted to the intensive care unit with necrotizing pancreatitis and biliary stenosis complicated by pneumonia, hypoxic respiratory failure, and convulsive seizures. The cardiology service was consulted to evaluate recurrent episodes of wide complex tachycardia observed on telemetry (Figure, A). The patient did not lose consciousness during these episodes.

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Rapid and accurate distinction between artifact and ventricular tachycardia (VT) is crucial. Misinterpretation of an artifact as VT can lead to unnecessary medical interventions, including initiation of antiarrhythmic drugs, diagnostic coronary angiograms, and even implantation of implantable cardiac defibrillators.2 Potential causes of artifact include patient motion such as brushing teeth, scratching, or intentional electrode manipulation, presence of other electronic devices such as a left ventricular assist device, and loose electrode contact.3

Features that help differentiate artifact from true VT include body movement during the wide complex tachycardia, absence of hemodynamic impairment, presence of normal beats in any ECG lead, and unstable ECG baseline before or after.4 Most importantly, if sharp spikes consistent with QRS complexes can be marched through the wide complex tachycardia, as in this case, the diagnosis is almost certainly artifact. The interval should be measured during 2 sinus beats preceding the wide complex tachycardia. That interval should then be marched forward through and beyond the tachycardia.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: David S. Frankel, MD, Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, 9 Founders Pavilion, Philadelphia, PA 19104 (david.frankel@pennmedicine.upenn.edu).

Published Online: April 11, 2022. doi:10.1001/jamainternmed.2022.0524

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by the JV and JV Fund in Cardiac Electrophysiology.

Role of the Funder/Sponsor: The JV and JV Fund had no role in the design and conduct of the study; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Dessertenne  F .  [Ventricular tachycardia with 2 variable opposing foci].   Arch Mal Coeur Vaiss. 1966;59(2):263-272.PubMedGoogle Scholar
2.
Knight  BP , Pelosi  F , Michaud  GF , Strickberger  SA , Morady  F .  Clinical consequences of electrocardiographic artifact mimicking ventricular tachycardia.   N Engl J Med. 1999;341(17):1270-1274. doi:10.1056/NEJM199910213411704PubMedGoogle ScholarCrossref
3.
Pérez-Riera  AR , Barbosa-Barros  R , Daminello-Raimundo  R , de Abreu  LC .  Main artifacts in electrocardiography.   Ann Noninvasive Electrocardiol. 2018;23(2):e12494. doi:10.1111/anec.12494PubMedGoogle ScholarCrossref
4.
Lin  SL , Wang  SP , Kong  CW , Chang  MS .  Artifact simulating ventricular and atrial arrhythmia.   Jpn Heart J. 1991;32(6):847-851. doi:10.1536/ihj.32.847PubMedGoogle ScholarCrossref
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