Examples of Rapid Atrial Flutter

My first post on 2:1 atrial flutter turned out to be one of my most popular and successful contributions to the FOAM world over the past few years, so I thought I’d go ahead and build on that a bit. Collected here are 50 different examples of rapid atrial flutter. Some are easy, most are a bit tricky, and a few a near-impossible; but they’re all atrial flutter. So, without further ado, get to it and start seeing atrial flutter.

EDIT (2013.11.21): Thanks to the keen eyes of EKG mavens David Richley and Ken Grauer, a couple of possible errors were spotted in the collection. #1134 is definitely NOT atrial flutter but rather AVNRT, though the patient was definitively in atrial flutter only 1 hour prior to that tracing. Also I will be taking another look at #0585, 0737, and 0808 to make sure those weren’t incorrectly included as well. A formal update and correction will be out this weekend.

4 thoughts on “Examples of Rapid Atrial Flutter

  1. @ Vince – Truly impressive collection! NIce the way you set this up – because I was able to go through all 50 tracings in no more than a few minutes. There are 4 tracings about which I was not all-but-convinced about AFlutter on = Tracings #0585; 0737 (David Richley shared my lack of conviction); 0808; and 1134. This is not to say that I didn’t think any of these 4 tracings were not AFlutter – but rather to indicate that I couldn’t make a near-definitive diagnosis based on this single 12-lead.

    I’d emphasize several teaching points regarding your wonderful collection:
    i) AFlutter is by far the most overlooked arrhythmia diagnosis (at least in my experience). Always suspect AFlutter whenever you have a regular SVT close to 150/min (140-160/min range) – and whenever you are not CERTAIN about the presence of sinus P waves.

    ii) Most of the time when you do not see a clear upright P wave in lead II during tachycardia – it is because the rhythm is NOT sinus.

    iii) IF the P wave in lead II is upright – but the PR interval during SVT is a “longish” amount – the chances are that this is NOT a sinus rhythm (the PR usually becomes shorter with tachycardia).

    iv) Be sure to look at ALL 12 leads – since clues to AFlutter as the diagnosis can be in ANY lead.

    v) Use calipers. The way to “look” for flutter waves – is to divide the R-R interval precisely in HALF – and then to see if you can find regularly occurring deflections in ANY lead that this half-R-R-interval amount.

    vi) Look for a “break” in the rhythm. That is – IF there is a PVC – look to see if what you suspect is flutter activity continues despite the PVC.

    vii) Step back a tiny bit from the tracing to see if you can now make out a “sawtooth” pattern.

    Use of the above vii features allowed me to rapidly and confidently confirm AFlutter for all but the above 4 tracings. Again – GREAT JOB Vince!

    • Vince D says:

      Thanks! I owe a lot to the creator of the Fullscreen Galleria plugin for WordPress (http://wordpress.org/plugins/fullscreen-galleria/) because it took me a while to find a gallery feature that is so clean and smooth to use. With the wrong setup no one would bother flipping past the first couple of ECG’s and the whole collection would go to waste.

      Those four tracings you mention are definitely the most difficult of the bunch and I wouldn’t expect anyone to pick them up without either old tracings or foreknowledge of the patient’s response to treatment. While I can “prove” the last three are flutter using other ECG’s and clinical information, #0585 is indeed a problem. I had actually intended to leave that one out of the collection because I couldn’t nail down whether it was 2:1 flutter or 1:1 atrial tachycardia, but it seems like it snuck back in while I was moving and editing the files. I’m going to see what I can track down on the case this weekend and if I can’t prove that it’s flutter I’ll replace it with another example. Thanks for having such a keen eye and spotting that in the midst of some much noise and bias leaning you towards just calling flutter.

  2. While not to expect that those 4 cases of AFlutter would be picked up – AFlutter SHOULD definitely be in the differential diagnosis for ALL of them! It’s just that the key point is that one needs to realize that additional information is needed in order to know one way or another. Again – GREAT job collecting and displaying these tracings Vince! – : )

    • Vince D says:

      Just took yet another glance at those tracings and it looks like you were right to be suspicious of 1134 as well. I wasn’t paying enough attention and while that patient was indeed in true rapid atrial flutter just an hour prior to that tracing, I have to agree that it looks like he bounced into an AVNRT for some reason. On the earlier tracing the flutter waves clearly map out and there a couple of 3:1 ratios, but that’s definitely not the case on the ECG I posted. I’ll clarify all of that with more ECG’s and info when I post a correction this weekend. Thanks again, and it’s a nice reminder of the cardiologist’s version of Hickam’s dictum: “Patients can have as many arrhythmias as they damn well please.”

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