ECG of the week

-Dr. Prof Mageshkumar’s Unit

Devendra Patil

Daniel , 50 / M came with chief complains of

Palpitations since 2 hrs

chest pain since 2 hrs

ECG was taken:

• ECG:Atrial rate 300Heart rate 75/minRegular rhythm4:1 constant blockNo iso electric baselineSaw tooth appearance in inferior leadsRsr’ in v1

Impression:Atrial flutter with incomplete RBBB

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)

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

• ECG Findings:

Atrial complexes of constant morphology polarity and cycle length

Presence of Flutter ( F ) wavesPicket fence appearance of F wavesSaw toothed appearance of F wavesNo iso-electric base lineUsually the atrial rate is 300 / min and there is a 2:1

block , so heart rate is 150 / minTypically leads II III and avF show negative F wavesLead V1 shows positive F waves and this may be

confused with sinus tachycardia

• 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

Few more ECGs

Etiology

• First week after open heart surgery

• COPD

• Mitral or tricuspid valve lesions

• Thyrotoxicosis

• Surgical correction of congenital heart disease

• Right atrial enlergement

Treatment

• Acute:cardioversion

• Longtermanti-coagulation ( similar to AF )anti-arrhythmics Catheter ablation of tractpacemaker insertion

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.

Long term treatment