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A 40-year-old man was referred for an atrial fibrillation (AF) ablation. Close examination of his Holter recording was suggestive of intermittent atrial activity (Panel A). The patient underwent a comprehensive electrophysiology study which demonstrated simultaneous fast and slow pathway activation, or ‘one for two’, due to dual AV nodal physiology (Panel B). Slow pathway modification eliminated the tachycardia.
Non-reentrant AV nodal tachycardia is rare, and can be mistaken for AF due to its irregular rhythm with difficult to visualize P-waves. Careful examination of the surface ECG can avoid an erroneous diagnosis of AF and institution of unnecessary therapy.
Conflict of interest: none declared.