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Year : 2016  |  Volume : 19  |  Issue : 3  |  Page : 402-403

Diaphragmatic flutter masquerading as palpitations

Department of Neurology, Aster Medcity, Kochi, Kerala, India

Date of Submission22-Dec-2015
Date of Decision26-Jan-2016
Date of Acceptance31-Jan-2016
Date of Web Publication25-Jul-2016

Correspondence Address:
Boby Varkey Maramattom
Department of Neurology, Aster Medcity, Kothad, Kochi - 682 023, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-2327.186843

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How to cite this article:
Maramattom BV, Sreekumar P, Kumar R A. Diaphragmatic flutter masquerading as palpitations. Ann Indian Acad Neurol 2016;19:402-3

How to cite this URL:
Maramattom BV, Sreekumar P, Kumar R A. Diaphragmatic flutter masquerading as palpitations. Ann Indian Acad Neurol [serial online] 2016 [cited 2023 Feb 3];19:402-3. Available from:

A 45-year-old lady presented episodes of palpitation for the last 8 years. As routine electrocardiography (ECG) was normal, she was taken up for cardiac electrophysiological study (EPS). During EPS, prior to starting stimulation, she had a typical episode. Fluoroscopy demonstrated high-frequency bilateral diaphragmatic flutter (DF) lasting for a few minutes, aborted by midazolam [Video]. Although, short episodes (<1 min) could be precipitated by deep breathing, the longer episodes were unpredictable, occurred 34 times a day, and lasted up to 30-45 min. These were not voluntarily suppressible. Intercostal electromyography (EMG) showed rhythmic discharges at 5-6 Hz during episodes and spirometry showed mild restriction with flutter in the flow volume loop [Figure 1] and [Figure 2]. She was started on carbamazepine 200 mg thrice daily
Figure 1: Right diaphragm EMG showing 6 Hz rhythmic discharges

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Figure 2: Spirograph showing flutter waves superimposed on flow volume loops

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DF is a rare movement disorder characterized by high-frequency involuntary diaphragmatic contractions. It presents with palpitations, dyspnea, inspiratory stridor, and chest pain and may go unrecognized for decades because of its rarity. [1] EMG of the intercostal muscles or diaphragm can show repetitive discharges of 9-15 Hz. Spirograph can demonstrate high-frequency oscillations superimposed on tidal respiratory movements in the flow loop curve. Carbamazepine may be useful in DF. [2] The diaphragm is under the control of two separate loops; an automatic reticulospinal circuit from medullary respiratory centers and a volitional circuit via the corticospinal tract from the motor cortex. Distinct types of DF may exist, including the isolated diaphragmatic tremor in which there is some degree of volitional suppressibility and minimal respiratory compromise. [3]

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Conflicts of interest

There are no conflicts of interest.

   References Top

Ramírez JD, Gonzales M, Hoyos JA, Grisales L. Diaphragmatic flutter: A case report and literature review. Neurologia 2015;30:249-51.  Back to cited text no. 1
Vantrappen G, Decramer M, Harlet R. High-frequency diaphragmatic flutter: Symptoms and treatment by carbamazepine. Lancet 1992;339:265-7.  Back to cited text no. 2
Espay AJ, Fox SH, Marras C, Lang AE, Chen R. Isolated diaphragmatic tremor: Is there a spectrum in "respiratory myoclonus"? Neurology 2007;69:689-92.  Back to cited text no. 3


  [Figure 1], [Figure 2]

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