Global pseudo-atrial flutter ECG appearance secondary to unilateral parkinsonian tremor.

To cite: Nam MCY, Best L, Greaves K, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2015214048 DESCRIPTION An 82-year-old man with previous bioprosthetic aortic valve replacement for aortic stenosis had a routine ECG (figure 1). This was thought to represent an atrial tachycardia with cycle length 280 ms and 3:1 atrioventricular response. A diagnosis of atrial flutter was made based on tachycardia cycle length, p-wave morphology and previous cardiac surgery. He had a mild left-sided tremor in keeping with known Parkinson’s disease. The patient was anticoagulated and admitted electively for an electrophysiology (EP) study. In the EP laboratory, the patient had a 12-lead ECG (figure 2A) showing sinus rhythm with a ventricular rate of 60 bpm. Figure 2B shows the EP electrogram recorded in the coronary sinus confirming sinus rhythm. However, it was noted that the ‘flutter waves’ in the original ECG were most marked in the left limb leads. In the EP laboratory, ECG labels are placed on the torso, as opposed to the limbs. After moving ECG labels to the forearms, the surface ECG is shown (figure 3) with re-emergence of ‘flutter’ waves. A diagnosis of pseudo-atrial flutter was made. Parkinsonian tremor characterised by a 5 Hz upper-limb dyskinesia can result in a pseudo p-wave artefact on ECG at a rate of 300 bpm, mimicking atrial flutter. 2 However, pseudo p-waves are usually only seen in the limb leads. We