Electrocardiography is the method of graphic tracing of the electric current of the cardiac muscle during heart beating. It represents a graph of voltage versus time of the electrical cardiac activity using electrodes placed on the skin [1-2]. It means a process of ECG or EKG production with a subsequent recording of electrical cardiac activity over repeated cardiac cycles [1]. These electrodes detect the small electrical changes that are a consequence of cardiac muscle depolarization followed by repolarization during each cardiac cycle (heartbeat). In a traditional 12-lead ECG, ten electrodes are placed on the patient's limbs and the surface of the chest. The ECG is very important to obtain information about 1. Chest pain, ischemic heart disease, and myocardial infarction. 2. Arrhythmias (such as atrial fibrillation and ventricular tachycardia). 3. Symptoms and signs such as shortness of breath, tachypnea, and murmurs. 4. Drug monitoring, such as (drug-induced QT prolongation and Digoxin toxicity). 5. Electrolyte disorders, such as hyperkalemia and hypocalcemia. Perioperative preparation for fitness. 6. Pericardial diseases such as pericarditis. 7. Genetic diseases screening and diagnosis, such as Brugada and WPW syndromes. 8. Suspicion of pulmonary embolism. 9. Cardiac stress testing. 10. Cardiac electrophysiology [3-6]. Unintentional misplacement of the limb lead electrodes is a frequent important problem during ECG processing (Table 1). This may produce a simulated pathology such as myocardial infarction, ischemia, arrhythmia, and chamber enlargement [7]. It had been reported that 0.4–4% of all 12-lead ECGs have been incorrect connection of the electrode cables. Unfortunately, most ECG textbooks only mention in short the most distinct findings of lead misplacement, such as negative P–QRS complexes in lead I or II and positive complexes in aVR lead [8]. So, less frequent cable misplacements may be less clear and often are missed by man and computers [9].

Table 1: Shows Some Common Reversed Lead Cables Position in The ECG.

RA; right arm, LA; left arm, LL; left leg, Clockwise rotation:

RA→LA→LL→RA, Anti-clockwise rotation: RA→LL→LA→RA. The (−) sign signifies that the relevant lead is inverted.

 Modified from (Burns Ed et al, 2021)

A 50-year-old housewife married female, Egyptian patient was presented to the emergency department (ED) with hyperventilation syndrome and non-specific chest pain after psychological stress. She gave a recent history of psycho-familial troubles for about 2 hours. Upon general physical examination; generally, the patient was tachypnic, anxious with a regular pulse rate of 70, blood pressure (BP) of 110/70 mmHg, respiratory rate of 22 bpm, GCS of 15/15, a temperature of 37°C, oxygen (O2) saturation of 99%. She seemed thin. No more relevant clinical data were noted during the clinical examination. The patient was refused to be referred to the ICU. Initially, she was treated with O2 inhalation (100%, by nasal cannula, 5L/min) and reassurance. The patient maintained monitoring for vital signs in the ED. CBC, liver function tests, and renal function tests were within normal. The troponin I test was normal (0.01 ng/ml). RBS was normal (98 mg/dl). The initial ECG tracing was done on the day of the presentation to the ED showing NSR of VR; 73. There is evidence of old inferior myocardial infarction with pathological Q–waves (II, III, and aVF) with T-wave inversion. There is a reversed characteristic of aVR lead to lead I (Figure 1A).

Figure 1: ECG Tracing Was Done On the Day of the Presentation to the ED Showing NSR of VR; 73. There Is Evidence of Old Inferior Myocardial Infarction with Pathological Q-Waves (Red Arrows; In II, III, and Avf) With T-Wave Inversion (Lime Arrows). There Is A Reversed Characteristic Of Avr Lead (Ovoid Brown Circle) To Lead I (Blue Brown Circle).

A caricaturing image for incorrect lead cables position for the initial ECG in the ED showing left to right lead reversal (Figure 1B).

Figure 2: A Caricaturing Image For Incorrect Lead Position Was Done For The Initial ECG Lead Cables Connection In The ED Showing Left To Right Lead Reversal. (Yellow, Red, Black, and Green Arrows).

Urgently the physician noticed that the present ECG findings are correlating with the patient status and there is something error. The second ECG tracing immediately was done within 5 minutes and after lead cables correction (Figure 2A).

Figure 3: ECG tracing was done after lead correction and within 5 minutes of the above ECG tracing showing NSR of VR; 71. There is a disappearance of evidence of the above old inferior myocardial infarction. There is reversed characteristic aVR lead (ovoid brown circle) and lead I (blue brown circle) to normal positions.

A caricaturing image after correction of lead cable position (Figure 2B).

Figure 4: A Caricaturing Image after Correction of Lead Cables Position (Red, Yellow, Black, and Green Arrows).

Later echocardiography showed no abnormalities detected with EF of 66%. New descriptive factitious Yasser's inferior myocardial infarction after circus limb leads in placement errors or left clockwise lead reversal was the most probable diagnosis. Future reassurance and follow-up were advised.

Overview:

A middle-aged housewife married female, Egyptian patient was presented to the ED with psychogenic hyperventilation syndrome and non-specific chest pain after psychological stress.

 The primary objective for my case study was the presence of unexpected and irrelevant evidence of old inferior myocardial infarction with pathological Q-waves (II, III, and aVF) and T-wave inversion in a patient with psychogenic hyperventilation syndrome in the ED.

The secondary objective for my case study was the question of how would you manage this case in the ED.

Interestingly, the presence of unexpected and irrelevant evidence of old inferior myocardial infarction with pathological Q-waves (II, III, and aVF) and T-wave inversion in a patient with psychogenic hyperventilation syndrome.

There is a reversed characteristic of aVR lead (ovoid brown circle) to lead I (blue brown circle) (Figure 1A and B).

There is a reversed characteristic aVR lead (ovoid brown circle) and lead I (blue brown circle) to normal positions (Figure 2A, B, and 3).

This technical error in limb leads reversal is a newly described innovative factitious Yasser's inferior myocardial infarction after circus limb leads in placement errors or left clockwise lead reversal (Figure 3).

Figure 5: A Caricaturing Image Showing a New Descriptive Factitious Yasser's Inferior Myocardial Infarction.

History, clinical data, and laboratory work up against diagnosis of inferior myocardial infarction.

Inferior myocardial infarction was the most probable differential diagnosis for the current case study. However, repeated readings for ECG will exclude it.

I can’t compare the current case with similar conditions. There are no similar or known cases with the same management for near comparison.

There are no limitations of the current study.

Factitious Yasser's inferior myocardial infarction is a technical error in limb lead reversal. It is a newly described innovation that happened after circus limb leads in placement errors or left clockwise lead reversal.

An accurate and immediate check-up for the ECG is a pivotal step in the initial interpretation. Understanding the ECG and its right processing before reading is highly remarkable.

Teaching the team nursing of critical care units and emergency departments and their follow-up is crucial. The diagnoses of the lead reversal need more repeated urgent visions and training on the initial ECG interpretations. Sudden unexpected change in the ECG is a serious cause of concern for physicians, especially, if ECG findings indicate for example myocardial infarction is unparalleled with the clinical cardiac symptoms.

Conflicts of interest

 There are no conflicts of interest.

Acknowledgment

 I wish to thank the team of doctors and nurses of the critical care unit in Kafr El-Bateekh Central Hospital for their technical support in helping me. I want to thank my wife for saving time and improving the conditions for supporting me.

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