ECG of the Week - 30th May 2016 - Interpretation

The following ECG is from an 82 yr old male with a history of severe pulmonary hypertension. He presents with worsening shortness of breath and hypoxaemia.

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Rate:

• Mean ventricular rate 132 bpm

Rhythm:

• Atrial flutter
• Variable block 2:1, 3:1

Axis:

• Right axis deviation

Intervals:

• QRS - Normal (100ms)

Segments:

• Minor ST depression inferior leads may be secondary to superimposed flutter waves

Additional:

• Flutter waves - rate ~300 bpm
• Negative flutter waves in inferior leads with positive waves in V1

Interpretation:

• Atrial Flutter
• Variable Block
• Typical Counter-clockwise flutter

What happened ?

The patient's significant underlying cardiac and pulmonary disease precluded DC cardioversion. He was treated with digoxin and following resolution of his hypoxaemia he reverted to sinus rhythm.

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.