ECG of the Week - 21st September 2015 - Interpretation

The following ECG is from a 70yr old who presented with lethargy. Past medical history of Aortic Valve Replacement with post operative AF. Vital signs: BP 85/60 RR 18 Sats 94% (Room Air). Check out the comments from our original post here.

Click to enlarge

Rate:

• Mean ventricular rate bpm
• Atrial rate ~300 bpm

Rhythm:

• Atrial flutter with variable high grade block (4:1 --> 10:1)

Axis:

• Normal

Intervals:

• QRS - Normal (80ms)

Segments:

• ST Depression leads V3-4 likely secondary to superimposed flutter waves

Additional:

• 'Saw tooth' baseline appearance
• Flutter waves - negative in inferior leads and positive in V1

Interpretation:

• Atrial flutter
• Typical counter-clockwise
• High grade variable block

What happened ?

Following discussion with the patient's cardiologist they were DC cardioverted with reversion to sinus rhythm and improvement in heart rate to 60-70 bpm.

More information on flutter classification / types:

• Medi C, Kalman JM. Prediction of the atrial flutter circuit location from the surface electrocardiogram. Europace (2008) 10, 786–796. FULL TEXT
• Pedrinazzi C, Durin O, Mascioli G, Curnis A, Raddino R, Inama G, Dei Cas L. Atrial flutter: from ECG to electroanatomical 3D mapping. Heart Int. 2006;2(3-4):161. FULL TEXT

Both papers provide in-depth reviews of atrial flutter classifications, both new & old, and how the ECG and advanced EP techniques can help differentiate them

References / Further Reading

Life in the Fast Lane

• Atrial Flutter

Textbook

• Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.