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JAMA Clinical Challenge
August 20, 2019

Electrocardiographic Diagnosis of Atrial Arrhythmias

Author Affiliations
  • 1Epidemiological Cardiology Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 2Department of Internal Medicine, Section on Cardiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 3Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis
JAMA. 2019;322(7):688-689. doi:10.1001/jama.2019.10925

A 65-year-old man who had been treated for hypertension for the past 10 years presented with increasing fatigue, dizziness, and palpitations. He did not have chest pain or any other symptoms. An electrocardiogram (ECG) was obtained (Figure 1).

Atrial fibrillation

B. Review the ECG for features of atrial fibrillation

The key to the correct diagnosis in this case is the absence of P waves, irregularly irregular R-R intervals, and fibrillary (f) waves on the ECG tracing. Careful analysis of the tracing is required to establish these features of atrial fibrillation (AF). Other dysrhythmias that have a similar appearance include frequent atrial ectopic beats, wandering atrial pacemaker, multifocal atrial tachycardia, and atrial flutter with varying AV block. These conditions may be distinguished from AF on the ECG by the fact that organized atrial activity would be present and denoted by the presence of distinct P waves, which are not seen on this tracing.

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