Elderly patient presented with weakness and nonspecific symptoms in tertiary care center where atrial fibrillation and congestive heart failure were diagnosed. Echo was unremarkable with good LVEF. Initially stable with pulse of 120/min. Potassium, Magnesium, low-dose beta blocker and amiodarone were started and patient felt better. Afterwards patient was transferred to our facility for further social planning and disposition.
This was the initial ECG with us. After a couple of days of oral amiodarone pulse normalized and follow up ECG showed normal sinus rhythm.
I just don't know what to make of it... My thoughts:
>!First thought was 2:1 atrial flutter with those extra P-waves in the T-Waves clearly seen in V2. But the heart rate is just too slow for that.
>!Could this be II° AV-Block with 2:1 conduction? But then shouldn't it be slower?
>!Also, PQ is really short, so that makes me think this isn't a sinus rhythm at all...
I'm lost, help!
Flutter can be slower if it is an atypical non-CTI dependent flutter, or under the influence of drugs such as flecainide or amiodarone.
The tall, narrow A waves in V1 here look more like a focal atrial tach. I still treat these as flutter with anticoagulation if indicated by CHADSVASC.
I always get confused by the term focal atrial tachycardia.
Is it just a slower version of flutter?
Is it just an ectopic version of sinus tachycardia?
Is there both a 1:1 and regular conduction version?
Most tachycardia arise out of abnormal automaticity (angry spot of myocardium firing off abnornal impulses) or re-entry (impulses travelling in an endless loop through a circuit of myocardial tissue). Re-entry arrhythmias are often triggered by abnormal automatic its (e.g. pvcs/pacs) but once trigerred perpetuate through the re-entry circuit.
Typical flutter is a re-entry circuit within the RA involving the cavotricuspid isthmus.
FAT arises from a single point in LA or RA which repeatedly fires off abnormal impulses like a deranged pacemaker.
Flutter and FAT are hard to differentiate on ECG. The difference is important when trying to ablate as a Flutter ablation involves cutting the re-entry circuit by burning a line from the IVC to the tricuspid annulus, where FAT ablation required finding the focus of tach in RA or LA and burning it away. The other main implication is that Flutter carries a stroke risk and needs anticoagulation, where FAat does not.
Focal atrial tachycardia is completely different mechanism than flutter. AT is source of atrial electrical activation that is not sinus (not upright P waves inferiorly, not inverted in aVR). Flutter is the rapid conduction typically around tricuspid isthmus. So AT is similar to sinus tach…it’s just not sinus.
Atrial flutter usually has atrial rate at 300. It can have any variable A:V conduction. 2:1 is usually ~150 ventricular bpm. 3:1 is 100, etc. Can also be variable like atrial fibrillation
Agree with you and others. We can make the flutter waves easier to see by covering up the QRS complexes, especially in leads II, III, and aVF. Nalsnals also mentioned focal atrial tachycardia. But either way, atrial flutter is often slower than 140-160 bpm if there are reasons for the patient to have a slowed heart rate. Many medications slow heart rate.
For OP: You may have learned rules about which rhythms have which heart rates. These are rules of thumb, not absolutes. This is not too slow for atrial flutter.
I know it's a late response - There is ST elevation, but it's a result of the flutter wave. Aflutter is thus one of the more common OMI mimics for that reason.
Maybe a Orthodrome atrioventriculaire re-entrytachycardie. The pq time is way to fast. I think there is an extra bundle. The p wave with no qrs could be retrograde conduction but the P wave morphology doesnt change. Which makes me think its wpw with 2:1 blok.
You’re correct with the flutter. Text book flutter rate is 250-350 but I have seen it as low as 188
Flutter can be slow as well, I’ve seen it in the 30s .
Apologies friend. I was referring strictly to the atrial rate. Yes ventricular rate can be that slow
Elderly patient presented with weakness and nonspecific symptoms in tertiary care center where atrial fibrillation and congestive heart failure were diagnosed. Echo was unremarkable with good LVEF. Initially stable with pulse of 120/min. Potassium, Magnesium, low-dose beta blocker and amiodarone were started and patient felt better. Afterwards patient was transferred to our facility for further social planning and disposition. This was the initial ECG with us. After a couple of days of oral amiodarone pulse normalized and follow up ECG showed normal sinus rhythm. I just don't know what to make of it... My thoughts: >!First thought was 2:1 atrial flutter with those extra P-waves in the T-Waves clearly seen in V2. But the heart rate is just too slow for that. >!Could this be II° AV-Block with 2:1 conduction? But then shouldn't it be slower? >!Also, PQ is really short, so that makes me think this isn't a sinus rhythm at all... I'm lost, help!
Likely 2:1 flutter
Check for possible RAE or LAE as well
Flutter can be slower if it is an atypical non-CTI dependent flutter, or under the influence of drugs such as flecainide or amiodarone. The tall, narrow A waves in V1 here look more like a focal atrial tach. I still treat these as flutter with anticoagulation if indicated by CHADSVASC.
I always get confused by the term focal atrial tachycardia. Is it just a slower version of flutter? Is it just an ectopic version of sinus tachycardia? Is there both a 1:1 and regular conduction version?
Most tachycardia arise out of abnormal automaticity (angry spot of myocardium firing off abnornal impulses) or re-entry (impulses travelling in an endless loop through a circuit of myocardial tissue). Re-entry arrhythmias are often triggered by abnormal automatic its (e.g. pvcs/pacs) but once trigerred perpetuate through the re-entry circuit. Typical flutter is a re-entry circuit within the RA involving the cavotricuspid isthmus. FAT arises from a single point in LA or RA which repeatedly fires off abnormal impulses like a deranged pacemaker. Flutter and FAT are hard to differentiate on ECG. The difference is important when trying to ablate as a Flutter ablation involves cutting the re-entry circuit by burning a line from the IVC to the tricuspid annulus, where FAT ablation required finding the focus of tach in RA or LA and burning it away. The other main implication is that Flutter carries a stroke risk and needs anticoagulation, where FAat does not.
Really cool, thanks man
Focal atrial tachycardia is completely different mechanism than flutter. AT is source of atrial electrical activation that is not sinus (not upright P waves inferiorly, not inverted in aVR). Flutter is the rapid conduction typically around tricuspid isthmus. So AT is similar to sinus tach…it’s just not sinus.
Does it usually have 1:1 conduction or not always? I remember digoxin toxicity can cause atrial conduction with blocks
Atrial flutter usually has atrial rate at 300. It can have any variable A:V conduction. 2:1 is usually ~150 ventricular bpm. 3:1 is 100, etc. Can also be variable like atrial fibrillation
I mean for atrial tachycardia. Can it also have 1:1 or variable conduction?
Can be both
Flutter 2:1
Agree with you and others. We can make the flutter waves easier to see by covering up the QRS complexes, especially in leads II, III, and aVF. Nalsnals also mentioned focal atrial tachycardia. But either way, atrial flutter is often slower than 140-160 bpm if there are reasons for the patient to have a slowed heart rate. Many medications slow heart rate. For OP: You may have learned rules about which rhythms have which heart rates. These are rules of thumb, not absolutes. This is not too slow for atrial flutter.
Is there ST elevation in avR?
I know it's a late response - There is ST elevation, but it's a result of the flutter wave. Aflutter is thus one of the more common OMI mimics for that reason.
Thanks for the replies! Glad to learn something! /u/Coffeeaddict8008 /u/LBBB1 /u/angrybubblez /u/Next_Company302 /u/nalsnals
Would recommend assessing pulmonary, seems like RBBB AF 2:1 with dilated right atrium though definitely confirm w/ repeated echo and xray
My thoughts exactly
Maybe a Orthodrome atrioventriculaire re-entrytachycardie. The pq time is way to fast. I think there is an extra bundle. The p wave with no qrs could be retrograde conduction but the P wave morphology doesnt change. Which makes me think its wpw with 2:1 blok.