Letters to the Editor
Case Report: Differentiating Artifact from True Ventricular Tachycardia
Figure. Toothbrushing mimicking wide-complex tachycardia. Portions of the QRS complexes are visible within the artifact (solid circles) at the sinus-cycle length (arrows).
TO THE EDITOR: A healthy 43-year-old man underwent Holter monitoring to evaluate palpitations. Electrocardiograms obtained at rest and after three minutes of step-test were normal, with heart rates of 58 and 102 beats per minute, respectively. Physical examination was unremarkable. The Holter monitor (see accompanying figure) showed an underlying sinus rhythm interrupted briefly by what appears to be wide-complex tachycardia. However, within the "ventricular tachycardia," QRS complexes were visible at intervals that coincided with the cycle length of the baseline rhythm. The rest of the Holter monitoring was normal. When asked what he had been doing during the event, the patient denied symptoms and explained that he had been brushing his teeth. Repeated Holter monitoring and an echocardiogram were unremarkable.
This case demonstrates characteristics that may be helpful in differentiating artifact from true ventricular tachycardia: the absence of symptoms during the event, normal QRS complexes within the arrhythmia, and an association with body movement.1
REFERENCES
1. Lin SL, Wang SP, Kong CW, Chang MS. Artifact simulating ventricular and atrial arrhythmia. Jpn Heart J 1991;32:847-51.
Exclusion Criteria Important in Use of Clinical Decision Rules
TO THE EDITOR: In the article, "Diagnosis and Treatment of Community-Acquired Pneumonia,"1 the discussion of outpatient versus inpatient treatment did not list the absolute contraindications to outpatient treatment. These contraindications include: hypoxemia (oxygen saturation less than 90 percent while patient is breathing room air), hemodynamic instability, active coexisting condition requiring hospitalization, and inability to tolerate oral medications.2 When applying a clinical decision rule to an individual patient, it is imperative to recognize exclusion criteria to avoid misapplication of the rule.
REFERENCES
1. Lutfiyya MN, Henley E, Chang LF, Reyburn SW. Diagnosis and treatment of community-acquired pneumonia. Am Fam Physician 2006;73:442-50.
2. Halm EA, Teirstein AS. Clinical practice: management of community-acquired pneumonia. N Engl J Med 2002; 347:2039-45.
editor's note: This letter was sent to the authors of "Diagnosis and Treatment of Community-Acquired Pneumonia," who declined to reply.
Send letters to Kenny Lin, M.D., assistant editor, American Family Physician, e-mail: afplet@aafp.org. Letters submitted via regular mail should be sent (on disk) to: 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-6272.
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