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ECG Diagnosis: Type I Atrial Flutter: Clinical Medicine

This document discusses type I atrial flutter, characterized by an inverted sawtooth flutter wave pattern in ECG leads II, III, and aVF, with upright F waves in leads V1 and inverted in V6. Type I atrial flutter is caused by a macro-reentrant circuit in the right atrium involving the cavotricuspid isthmus. The initial treatment focuses on rate control with AV nodal blocking agents, while electrical cardioversion is used for unstable patients. Adenosine or Valsalva maneuvers may help identify rhythm if unclear on ECG.

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80 views

ECG Diagnosis: Type I Atrial Flutter: Clinical Medicine

This document discusses type I atrial flutter, characterized by an inverted sawtooth flutter wave pattern in ECG leads II, III, and aVF, with upright F waves in leads V1 and inverted in V6. Type I atrial flutter is caused by a macro-reentrant circuit in the right atrium involving the cavotricuspid isthmus. The initial treatment focuses on rate control with AV nodal blocking agents, while electrical cardioversion is used for unstable patients. Adenosine or Valsalva maneuvers may help identify rhythm if unclear on ECG.

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ONLINE ONLY

CLINICAL MEDICINE

ECG Diagnosis: Type I Atrial Flutter


Steven Foy, MD; Joel T Levis, MD, PhD, FACEP, FAAEM Perm J 2014 Spring;18(2):e128
http://dx.doi.org/10.7812/TPP/13-132

Atrial flutter (AFl) is a cardiac dysrhythmia character-


ized by rapid and regular depolarization of the atria that
appears as a sawtooth pattern on the electrocardiogram
(ECG) and is categorized into type I (typical) and type
II (atypical) AFl.1 The ECG in type I (typical) AFl is
characterized by an inverted sawtooth flutter (F) wave
pattern in the inferior leads II, III, and aVF, low ampli-
tude biphasic F waves in leads I and aVL, an upright F
wave in precordial lead V1, and an inverted F wave in
lead V6.2 Type I AFl is most commonly caused by the
presence of a macro-reentrant circuit in the right atrium
that includes a small strip of tissue between the inferior
vena cava and the tricuspid annulus known as the
Figure 1. 12-lead electrocardiogram from a 54-year-old man with palpitations and
cavotricuspid isthmus.3 The ECG in atypical (type II) light-headedness for 3 hours. Demonstrates an irregularly-irregular rhythm with a
AFl is characterized by upright F waves in leads II, ventricular rate of approximately 127 beats/minute.
III, aVF, and V6 and by biphasic F waves in leads I,
aVL, and V1. The underlying mechanism of type II AFl
is unclear.1 Risk factors for AFl include presence of
heart failure, chronic obstructive pulmonary disease,
antiarrhythmic medications, thyrotoxicosis, pulmonary
embolism, prior cardiac surgery or prior atrial ablation.
Common symptoms of AFl include palpitations, light-
headedness, fatigue, presyncope, mild shortness of
breath, and possibly chest pain or hypotension. The
initial treatment for AFl focuses on rate control of the
ventricular response with AV nodal blocking agents
such as beta-blockers and calcium channel blockers.4
If rhythm identification is unclear and the patient is
stable, adenosine or Valsalva maneuver may be em- Figure 2. Rhythm strips (leads II, aVF, and V5) from same patient during
ployed to slow conduction through the AV node such administration of 12 mg intravenous adenosine. Demonstrates type I atrial
flutter waves with slowing of AV conduction.
that the atrial flutter waves are more readily apparent.1
Hemodynamically unstable patients with AFl should
receive synchronized electrical cardioversion.1 v

References
1. Filippone LM, Caldwell CC. Chapter 28: Can the electrocar-
diogram determine the rhythm diagnosis in narrow complex
tachycardia. In: Brady WJ, Truwit JD, editors. Clinical Decisions
in Emergency and Acute Care Electrocardiography. West Sus-
sex, UK: Wiley-Blackwell; 2009. p 240-41.
2. Sawhney NS, Anousheh R, Chen WC, Feld GK. Diagno-
sis and management of typical atrial flutter. Cardiol Clin
2009 Feb;27(1):55-67. DOI: http://dx.doi.org/10.1016/j.
ccl.2008.09.010.
3. Granada J, Uribe W, Chyou PH, et al. Incidence and predictors
of atrial flutter in the general population. J Am Coll Cardiol
2000 Dec;36(7):2242-6. DOI: http://dx.doi.org/10.1016/
S0735-1097(00)00982-7. Figure 3. 12-lead electrocardiogram from same patient following synchronized
4. Hood RE, Shorofsky SR. Management of arrhythmias in the electrical cardioversion with 200 Joules demonstrates sinus rhythm with premature
emergency department. Cardiol Clin 2006 Feb;24(1):125-33,
atrial contractions (PACs).
vii. DOI: http://dx.doi.org/10.1016/j.ccl.2005.09.005.

Steven Foy, MD, is an Emergency Medicine Resident in the Stanford/Kaiser Emergency Medicine Residency Program in CA.
E-mail: sfoy@stanford.edu. Joel T Levis, MD, PhD, FACEP, FAAEM, is a Senior Emergency Medicine Physician at the Santa
Clara Medical Center, and Clinical Assistant Professor of Emergency Medicine (Surgery) at Stanford University. He is the
Medical Director for the Foothill College Paramedic Program in Los Altos, CA. E-mail: joel.levis@kp.org.

e128 The Permanente Journal/ Spring 2014/ Volume 18 No. 2

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