ECG: Atrial Flutter
- 1. ECG of the week Dr. Prof Mageshkumar’s Unit Devendra Patil
- 2. Daniel , 50 / M came with chief complains of Palpitations since 2 hrs chest pain since 2 hrs ECG was taken:
- 5. ECG: Atrial rate 300 Heart rate 75/min Regular rhythm 4:1 constant block No iso electric baseline Saw tooth appearance in inferior leads Rsr’ in v1 Impression: Atrial flutter with incomplete RBBB
- 6. Atrial Flutter Mechanism: macro re-entrant tract in the atria Types: - right / left re-entrant tract - counterclockwise / clockwise tract - typical /reverse typical / atypical - regular / irregular rhythm - isthumus dependent / non dependent (recent)
- 7. Typical atrial flutter Pathway: in the typical form the re-entrant wavefront moves from up in the interatrial septum and then down the free right atrial wall. i.e. counterclockwise Tract location : cavo – tricuspid isthumus
- 9. ECG Findings: Atrial complexes of constant morphology polarity and cycle length Presence of Flutter ( F ) waves Picket fence appearance of F waves Saw toothed appearance of F waves No iso-electric base line Usually the atrial rate is 300 / min and there is a 2:1 block , so heart rate is 150 / min Typically leads II III and avF show negative F waves Lead V1 shows positive F waves and this may be confused with sinus tachycardia
- 10. ECG findings: Very rapid Venticular rates makes ECG diagnosis difficult The F waves may superimpose on the terminal QRS and the T waves and make the diagnosis difficult Use of vagal manuovers or Inj. Adenosine to transiently increase the AV delay may unmask the flutter waves Clockwise Atrial flutter: positive waves in inferior leads and V1 shows a biphasic or sometimes negative F waves
- 11. Few more ECG s
- 16. Etiology First week after open heart surgery COPD Mitral or tricuspid valve lesions Thyrotoxicosis Surgical correction of congenital heart disease Right atrial enlergement
- 17. Treatment Acute: cardioversion Longterm anti-coagulation ( similar to AF ) anti-arrhythmics Catheter ablation of tract pacemaker insertion
- 18. Cardioversion External trans thoracic syncronised DC shock is highly effective Intravenous Ibulitide or procainamide can also be used Care should be taken during use of class 1 esp 1C agents because they may slow the atrial rate and an inadequately suppressed AV node may give way to 1:1 conduction leading to high rates and circulatory collapse.