Another example of Aslanger’ s sign

he arterial pulse tapping artifact, known as Aslanger's sign, is an electrocardiographic artifact resulting from the transmission of arterial pulsation onto the limb electrodes of the standard 12lead electrocardiograph (ECG) which are placed near the radial or posterior tibial arteries. [1][2][3]3][4][5][6][7][8][9][10][11][12][13][14][15][16] This electromechanical artifact is of cardiac origin and is synchronous with the cardiac cycle. [17]Nearly all reported cases of Aslanger's sign exhibit an unusual waveform morphology in all 12 leads except one limb lead. [1][2][3][4]4][5][6][7][8][9][10][11][12][13][14]16] However, we previously reported a case of Aslanger's sign that showed distorted waveforms from the ST to TP segments observed only in five limb leads among 12 leads. [15]In that report, we speculated that Aslanger's sign could appear in a wide range of cases, from those with marked waveform changes in 11 leads [1][2][3][4][5][6][7][8][9][10][11][12][13][14]16] to those with no or subtle involvement in all precordial leads and even in some limb leads. [15]In this report, we present another case of Aslanger's sign with slightly downsloping or upsloping TP segment only observed in five limb leads of the standard 12-lead ECG.The distorted waveforms disappeared on the ECG, which was re-recorded with attention to the position of the limb electrodes.A 74-year-old Japanese man presented to our hospital for a follow-up of mild left ventricular dysfunction with an ejection fraction of 50%-60% of unknown cause.He did not report chest pain or dyspnea at presentation and had no history of smoking or alcohol consumption.His significant medical history included idiopathic pericarditis without sequelae four years ago.The patient was not taking any medication.Blood tests showed an elevated brain natriuretic peptide level of 58.2 pg/mL (reference range: 18.4 pg/mL) but a normal high-sensitivity cardiac troponin I level of 3.4 pg/mL (reference range: 18.4 pg/mL).A standard 12-lead ECG revealed a downsloping TP seg-