Tremors Mimicking Atrial Flutter in an Elderly Lady - Juniper Publishers

Juniper Publishers- Open Access Journal of Case Studies

Tremors Mimicking Atrial Flutter in an Elderly Lady

Authored by Aamir Hameed Khan

Abstract

We present an interesting case where electrocardiogram (ECG) recording in a patient with tremors mimics atrial flutter. A 77-year-old south Asian lady with history of hypertension and Parkinson`s disease presented to a tertiary care hospital in Pakistan with cough and fever. On second day of admission she started having pleuritic chest pain, Initial ECG was interpreted as atrial flutter. When her ECG was reviewed by a cardiologist, several features questioned the diagnosis of atrial flutter. A repeat 12 lead ECG clearly demonstrated normal sinus rhythm and the patient remained completely asymptomatic throughout the hospital stay. Tremor induced artifacts can be mistaken for arrhythmias. Correct diagnosis is critically important, in order to avoid wrong treatment and unnecessary interventions.

Keywords:Tremors; Atrial flutter; Parkinson`s disease

Introduction

Parkinson’s disease is a degenerative neurological disease caused by the loss of dopaminergic neurons in the substantia nigra [1]. Around 2% of the population above the age of 65 years develop Parkinson`s disease. Parkinson`s is characterized by bradykinesia, rigidity, postural and gait impairment, and resting tremors.

Atrial flutter is a macro reentrant supraventricular tachyarrhythmia characterized by an atrial rate of more than 300 beats/minute with the saw-tooth appearance of p waves [2]. Patients with atrial flutter commonly present with palpitations, fatigue, dizziness. Sometimes transient ischemic attacks or stroke may be the initial manifestation of atrial flutter. Other than thromboembolism, atrial flutter is associated with tachycardia induced cardiomyopathy, and heart failure [3]. Without proper anticoagulation, the risk of cerebral embolization with atrial flutter is equal to atrial fibrillation [3].

12 electrocardiogram plays a pivotal role in the diagnosis of atrial flutter and electrocardiographic artifacts are a common finding in the in-patient setting [4]. It is reasonable to consider the possibility of artifacts while making a diagnosis of tachyarrhythmia, this may save an unnecessary intervention in the form of antiarrhythmic medications, anticoagulation and even electrical cardioversion. Parkinsonian tremors are one of the major causes of electrocardiographic artifacts resembling atrial flutter. We present an interesting case of tremors mimicking atrial flutter and will discuss the existing literature

Case Presentation

A 77-year-old south Asian female with a history of hypertension and Parkinson`s disease presented to a tertiary care hospital in Pakistan with 2 days history of fever and nonproductive cough. She denied chest pain, shortness of breath, palpitations and syncope. Her home medications included carbidopa-levodopa, amlodipine, multivitamins and esomeprazole. On initial examination her heart rate was 96 beats per minute, blood pressure was 100/70mmHg; the respiratory rate was 18 breaths per minute and she was afebrile. Her chest exam revealed signs of consolidation in right lower lung zone. The neurological exam showed bilateral resting tremors and rigidity in both the upper and lower extremities. Her initial laboratory investigations included hemoglobin of 11.9g/dl, total leukocyte count 9400/micL, sodium of 135mmol/L, potassium of 3.9mmol/L, chloride of 102mmol/L, creatinine of 0.8mg/dl, magnesium of 2.1mg/dl, and pro-BNP of 19. Her x-ray chest demonstrated right lower lung zone alveolar infiltrates with air bronchogram.

She was admitted and started on intravenous antibiotics along with intravenous hydration and antipyretics as needed. On the second day of hospitalization, she started having right-sided pleuritic chest pain. Cardiac monitor and rhythm strip showed atrial flutter (Figure 1). Initial 12 lead ECG was interpreted as atrial flutter (Figure 2).

After review of her ECG by a cardiologist, several ECG features including sharply contoured p waves, different “flutter” wave morphologies in the same leads and more prominent “flutter” waves in the limb leads compared to the precordial leads, questioned the diagnosis of atrial flutter. A repeat 12 lead ECG was done after immobilizing her limbs, which clearly demonstrated normal sinus rhythm (Figure 3).

Discussion

Artifacts in electrocardiograms are common in a hospital setting. These artifacts can mimic several arrhythmias leading to unnecessary and potentially harmful interventions in the form of antiarrhythmic drugs and even electrical cardioversion [5]. In our patient, a misdiagnosis of atrial flutter could have led to lifelong anticoagulation as her CHA2DS2-VASc score was 4.

Hwang et al. [6] enrolled 100 patients with Parkinson`s disease with resting tremors to study the frequency and patterns of tremor-induced artifacts in an outpatient setting. The study demonstrated baseline undulation in 78% of the patients and artifacts mimicking atrial flutter/fibrillation or ventricular tachycardia were found in 11% of the patients [6]. 12 lead ECGs were evaluated by postgraduate, neurology residents, internal medicine residents and cardiologists, who were given relevant medical information. The rate of ECG misinterpretation leading to the spurious diagnosis of atrial flutter /fibrillation or ventricular tachycardia was 14.3% with an automated electrocardiograph, 45% with postgraduate year one resident and 9.1% with neurology residents, Cardiology residents and fellows correctly identified all artifacts, indicating the importance of professional training to reduce the potential complications [6].

Tremor induced artifact can be misinterpreted as supraventricular as well as ventricular arrhythmias. Several clinical and electrocardiographic characteristics should be observed o differentiate tremor induced artifacts from cardiac arrhythmias. While recording 12 lead ECGs, it is mandatory to minimize environmental interference, such as patient movement, electromagnetic interference from cell phones and tremors [7]. ECG characteristics which suggest tremor induced “pseudo” atrial flutter, include abrupt onset and termination, presence of normal p wave before and after arrhythmia, atypical p wave morphology with sharp contours, prominence flutter waves in limb leads and on careful inspection the presence of normal p wave that marches out throughout the event. In the setting of suspected tremor induced ventricular arrhythmias, hemodynamic stability is expected and supports the artifacts.

It is essential to note that Parkinsonian tremor is present in the limbs and face but not in the trunk; therefore, the tremor induced artifacts are more prominent in limb-leads as compared to the precordial leads.

Prescription of anticoagulation with the spurious diagnosis of atrial flutter increases the risk of serious intracranial hemorrhage in patients with advanced age and Parkinson`s disease as they are at increased risk of falls due to postural instability [8]. It leads to unnecessary emotional stress on patients and families and associated hospital/clinical visits contribute towards increasing health care cost burden.

Conclusion

In conclusion, our case report highlights several differentiating electrocardiographic features of tremor induced artifacts Correct and accurate diagnosis requires careful inspection and interpretation of the ECG in the context of history and clinical examination. This is critically important, to avoid wrong treatment and unnecessary interventions.

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