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Challenges in Clinical Electrocardiography |

A Case of P-Wave Mimicry Cherchez le P

Jordan C. Ray, MD1; Fred Kusumoto, MD2; Nora Goldschlager, MD3,4
[+] Author Affiliations
1Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida
2Division of Cardiovascular Disease, Department of Medicine, Mayo Clinic, Jacksonville, Florida
3Division of Cardiology, Department of Medicine, San Francisco General Hospital
4Department of Medicine, University of California–San Francisco
JAMA Intern Med. 2015;175(10):1693-1694. doi:10.1001/jamainternmed.2015.3342.
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Test your knowledge with an electrocardiogram quiz case involving P-wave mimicry.

A man in his 60s presented to the emergency department with chest pain. He had a history of hypertension but no other cardiac history. His pain was described as a dull ache localized to his epigastrium; it had been constant for 4 hours, did not radiate, and was not exacerbated by exertion. Examination of the heart, lungs, and abdomen had normal results. A chest x-ray revealed no acute cardiopulmonary process. An electrocardiogram (ECG) was obtained and is shown in Figure 1.

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Figure 1.
Initial Electrocardiogram Showing Atrial Ectopic and Junctional Rhythms and P-Wave Mimicry
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Figure 2.
Lead II Showing Atrioventricular Dissociation Represented by the Independent Atrial and Ventricular Depolarizations

Vertical arrowheads indicate independent atrial depolarizations, and double-headed horizontal arrows, ventricular depolarizations.

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Figure 3.
Electrocardiogram Tracings With P-Wave Mimicry

A, Lead I, upright P wave and short PR interval presents as a “pseudodelta wave” (arrowheads). B and C, Leads II and III show inverted P wave, suggesting junctional rhythm with “pseudo-Q wave” (arrowheads). D, Lead V6 shows inverted P wave following the QRS complex, which presents as a “pseudo-S wave” and the appearance of conduction delay (arrowheads).

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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