ECG of the week

-Dr. Prof Mageshkumars Unit Devendra Patil

Daniel , 50 / M came with chief complains of Palpitations chest pain ECG was taken: since 2 hrs since 2 hrs

 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

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 ) 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

 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 Longterm anti-coagulation ( similar to AF ) anti-arrhythmics Catheter ablation of tract pacemaker 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