Gone with the lead: the arterial pulse-tapping artifact-a systematic review of case reports

First described in 2010, the arterial pulse-tapping artifact is an ECG pattern that mimics ischemic ST-T abnormalities. Yet, the literature remains fragmented, largely confined to case reports. We systematically evaluated the electrocardiographic characteristics, clinical features, and outcomes of all reported cases. Pubmed, Embase, Scopus, and Google Scholar were searched from inception to May 2025. Studies written in English describing at least one patient with arterial pulse-tapping artifact were included. Altogether, 31 case reports or series describing 34 patients were included. Mean age was 53.1 ± 17.7 years, with a male predominance (65%). Chest pain-mostly atypical-was the most common symptom (44%), followed by dyspnea (9%), and syncope, weakness, or dizziness (6% each). ST-T abnormalities were diffusely distributed, sparing one limb lead-most often lead II (41%), III (33%), or I (26%). ST-elevation appeared in 91% of cases, with ≥ 3 lead involvement in 44%, though only a minority aligned with a coronary territory. One-fourth of the patients-all over 50 years of age, with equal gender distribution-underwent emergent coronary angiography, with one case demonstrating significant stenosis. Identifiable causes of hyperdynamic circulation were present in only 15%, including hemodialysis, cirrhosis, and pregnancy. The arterial pulse-tapping artifact remains inadequately recognized among emergency physicians and cardiologists, frequently leading to unnecessary interventions. Recognition of unusual ECG waveforms with sparing of a single limb lead should raise suspicion for this artifact. The upper limbs are responsible for the majority of cases.