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An Unusual Tracing

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JAMA Internal Medicine

Published Online: April 24, 2023

Challenges in Clinical Electrocardiography

Article Information and Disclosures

Sameer Kassem, MD, PhD¹;

Jochanan E. Naschitz, MD¹

Author Affiliations

¹Bait Balev Nesher and The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel

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A patient in their 90s was admitted for palliative care. The main diagnoses were end-stage dementia, pressure ulcers, extrapyramidal syndrome, paroxysmal atrial fibrillation, and hypothyroidism. The patient’s medications were bisoprolol fumarate, 2.5 mg; flecainide acetate, 50 mg; levothyroxine, 50 µg; and aspirin, 100 mg. On the second day of residence in the hospital, the patient experienced a massive aspiration of gastric content. The patient was treated conservatively. An electrocardiogram (ECG) was recorded.

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A patient in their 90s was admitted for palliative care. The main diagnoses were end-stage dementia, pressure ulcers, extrapyramidal syndrome, paroxysmal atrial fibrillation, and hypothyroidism. The patient’s medications were bisoprolol fumarate, 2.5 mg; flecainide acetate, 50 mg; levothyroxine, 50 µg; and aspirin, 100 mg. On the second day of residence in the hospital, the patient experienced a massive aspiration of gastric content. The patient was treated conservatively. An electrocardiogram (ECG) was recorded.

Questions: What is the basic rhythm? Do the large waves, those interfering with the basic rhythm, express a genuine ventricular arrhythmia? Does the ST-T segment shift denote an acute coronary event?

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Article Information

Corresponding Author: Sameer Kassem, MD, PhD, POB 252, Nesher 36602, Derech Hashalom 11, Haifa 36602, Israel (sameerkassem@gmail.com).

Published Online: April 24, 2023. doi:10.1001/jamainternmed.2023.0298

Conflict of Interest Disclosures: None reported.

References

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.12494 PubMed Google Scholar Crossref

AlMahameed ST , Ziv O . Ventricular arrhythmias. Med Clin North Am. 2019;103(5):881-895. doi:10.1016/j.mcna.2019.05.008 PubMed Google Scholar Crossref

Huang CY , Shan DE , Lai CH , et al. An accurate electrocardiographic algorithm for differentiation of tremor-induced pseudo-ventricular tachycardia and true ventricular tachycardia. Int J Cardiol. 2006;111(1):163-165. doi:10.1016/j.ijcard.2005.06.017 PubMed Google Scholar Crossref

Ardhanari S , Shah AJ , Thakur RK . Myocardial infarction—fusion or confusion? J Invasive Cardiol. 2009;21(9):E164-E165.PubMed Google Scholar

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.