Causes of tremor artifact

  Tight fastening of the extremity electrodes

  Anxiety

  Parkinson's disease

  Hyperthyroidism







ECG 1. Tremor artifact. Although it resembles atrial fibrillation at a first glance, observation of equal R-R intervals and P
waves in V4, V5 confirms that the rhythm is not atrial fibrillation.

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ECG 2a. Looks like atrial flutter at first glance. The rhythm tracing at the bottom of the ECG resembles ventricular fibrillation.

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ECG 2b. The ECG repeated immediately shows the sinus rhythm.

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ECG 3. The artifact on this Holter recording at first resembles ventricular tachycardia. Although
this Holter recording includes 12 leads, only D3 shows the regular sinus rhythm ruling out
ventricular tachycardia. This type of artifact is more difficult to recognize in Holter recordings
using 3 leads.

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ECG 4a. If you are monitorizing this patient from lead III, you may think it as ventricular fibrillation (VF) at first glance.

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ECG 4b. The ECG repeated immediately shows the sinus rhythm.

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ECG 5a. The ECG above belongs to a 62 years-old woman who had attacks of paroxysmal atrial fibrillation. She stopped her
Paroxetin therapy abruptly, after which an unmanageable tremor started. This ECG gives the impression of atrial flutter at
first glance. The
tremor artifact seen in many leads gives this impression. However careful inspection of the leads V4 to V6
shows the
P waves and the diagnosis is sinus rhythm. These waves have different shapes than the tremor artifact preceding
them
.

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ECG 5b. A second ECG was recorded immeadiately. This time the tremor artifact was more clear in lead V1. In patients with
atrial flutter, the flutter waves are more regular and look like to each other. On the other hand, the tremor artifact in V1 are
irregular and do not look like each other.

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ECG 6. Oscillating irregular baseline and irregular RR intervals do not always denote atrial fibrillation.
In the presence of baseline drift and/or tremor artifact
P waves may be difficult to detect at first glance.
In the 6-channel ECG above, the basic rhythm is sinus with
first degree AV block ( prolonged PR interval )
The precordial recording shows two VPCs.
Terminal portion of the first VPC and the second VPC are seen.

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ECG 7a. The above ECG is from a 59 years-old man with old anterior myocardial infarction.
The limb leads give the impression of atrial flutter at first glance.
However, the precordial leads clearly show P waves, excluding the diagnosis of atrial flutter.

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ECG 7b. The ECG was repeated one minute later (above). Now, the limb leads lack the tremor artifact and show P waves clearly.

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ECG 8. The rhythm in the above ECG looks like atrial fibrillation at first glance. However the RR intervals are similar.
The rhythm is not atrial fibrillation. Prominent tremor artifact falsely gives the impression of atrial fibrillation at first glance.

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ECG 9a. In the above ECG, some limb leads may look like ventricular fibrillation at first glance.

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ECG 9b. Above ECG belongs to the same patient. It was recorded 15 seconds after ECG 9a.

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