There is a very rapid, regular narrow-complex tachycardia at 250-300 bpm
Flutter waves are not clearly seen, but there is an undulation to the baseline in the inferior leads suggestive of flutter with a 1:1 block
Alternatively, this may just be rapid SVT (AVNRT/AVRT) with rate-related ST depression
With ventricular rates as rapid as this, spending any further time evaluating the ECG is unwise! Resuscitation is the priority… This patient will almost certainly be haemodynamically unstable, requiring emergent DC cardioversion.
Narrow complex tachycardia at 150 bpm
There are no visible P waves
Sawtooth baseline in V1 with flutter waves visible at 300 bpm
Elsewhere, flutter waves are concealed in the T waves and QRS complexes
The heart rate of 150 bpm makes this flutter with a 2:1 block
NB. Flutter waves are often very difficult to see when 2:1 block is present.
📌Suspect atrial flutter with 2:1 block whenever there is a regular narrow-complex tachycardia at 150 bpm — particularly when the rate is extremely consistent
📌In contrast, the rate in sinus tachycardia typically varies slightly from beat to beat, while in AVNRT/AVRT the rate is usually faster (170-250 bpm)
📌To differentiate between these rhythms, try some vagal manoeuvres or give a test dose of adenosine — AVNRT/AVRT will often revert to sinus rhythm, whereas slowing of the ventricular rate will unmask the underlying atrial rhythm in sinus tachycardia or atrial flutter
📌In contrast, the rate in sinus tachycardia typically varies slightly from beat to beat, while in AVNRT/AVRT the rate is usually faster (170-250 bpm)
📌To differentiate between these rhythms, try some vagal manoeuvres or give a test dose of adenosine — AVNRT/AVRT will often revert to sinus rhythm, whereas slowing of the ventricular rate will unmask the underlying atrial rhythm in sinus tachycardia or atrial flutter
ST deviations: Flutter vs. MI
📌AFlutter may cause inferior ST deviations, which mimic lateral OMI (to confuse matters, reciprocal changes may be seen in the inferior leads!).
📌Features favoring ST deviation due to Flutter alone (i.e., benign changes):
ST changes are small (e.g., equal to or smaller than the size of the flutter waves in the same lead).
Lead aVL may be especially helpful here.
📌 The distribution of ST changes doesn't fit with any pattern of occlusive MI (e.g., STE in aVL and STD in lead I).
📌 Sorting this out using the ECG may not always be possible. STAT echocardiography or immediate DC cardioversion may be needed to clarify the diagnosis.
📌AFlutter may cause inferior ST deviations, which mimic lateral OMI (to confuse matters, reciprocal changes may be seen in the inferior leads!).
📌Features favoring ST deviation due to Flutter alone (i.e., benign changes):
ST changes are small (e.g., equal to or smaller than the size of the flutter waves in the same lead).
Lead aVL may be especially helpful here.
📌 The distribution of ST changes doesn't fit with any pattern of occlusive MI (e.g., STE in aVL and STD in lead I).
📌 Sorting this out using the ECG may not always be possible. STAT echocardiography or immediate DC cardioversion may be needed to clarify the diagnosis.
📌 Flutter is usually a short-lived transitional state, which either degenerates into atrial fibrillation or converts to sinus rhythm. As a transitional state, atrial flutter often resembles new-onset atrial fibrillation (NOAF).
📌 The management of atrial flutter is similar to that of AF, but a rhythm control strategy is more effective for the following reasons:
(1) Rate control in atrial flutter is often difficult (the heart rate tends to get “stuck” at ~150 b/m).
(2) Atrial flutter is often a transient state that is relatively easy to cardiovert into normal sinus rhythm.
📌 The management of atrial flutter is similar to that of AF, but a rhythm control strategy is more effective for the following reasons:
(1) Rate control in atrial flutter is often difficult (the heart rate tends to get “stuck” at ~150 b/m).
(2) Atrial flutter is often a transient state that is relatively easy to cardiovert into normal sinus rhythm.
acute management of atrial flutter
⏺️Rhythm control may be considered, but this is particularly difficult and often fails.
⏺️ Electrical cardioversion is highly effective (but it does require procedural sedation).
⏺️ Ibutilide ⚡️ is generally effective. (31504425)
⏺️ Amiodarone ⚡️ is less effective at acute cardioversion, but it does help control the ventricular rate.
⏺️ Anticoagulation management is modeled off the treatment of atrial fibrillation (although the thromboembolic risk may be lower than with atrial fibrillation)
⏺️Rhythm control may be considered, but this is particularly difficult and often fails.
⏺️ Electrical cardioversion is highly effective (but it does require procedural sedation).
⏺️ Ibutilide ⚡️ is generally effective. (31504425)
⏺️ Amiodarone ⚡️ is less effective at acute cardioversion, but it does help control the ventricular rate.
⏺️ Anticoagulation management is modeled off the treatment of atrial fibrillation (although the thromboembolic risk may be lower than with atrial fibrillation)
chronic management of atrial flutter
Catheter ablation is effective.
Medication therapy:
1st line: Rate control with beta-blocker, diltiazem, or verapamil.
2nd line: Rhythm control with amiodarone.
Catheter ablation is effective.
Medication therapy:
1st line: Rate control with beta-blocker, diltiazem, or verapamil.
2nd line: Rhythm control with amiodarone.
2019 SVT Guidelines (for the management of patients with).pdf
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2019 Guidelines on Supraventricular Tachycardia (for the management of patients with)
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