ECG Blog #535 — A "Fluttering" ECG ...

The limb leads shown in Figure-1 were recorded from a middle-aged man with diabetes and hypertension.

• Is this patient in Atrial Flutter (AFlutter) with 3:1 or 4:1 AV conduction?

   

Figure-1: The initial ECG in today's case — obtained from a middle-aged man with diabetes and hypertension. (To improve visualization — I've digitized the original ECG using PMcardio).

Answer:

When this tracing was posted on the internet — more than half of the 70+ respondents thought the rhythm was either AFib or AFlutter.

• The large amplitude deflections in Figure-1 that simulate flutter waves are artifact. I do not know what the actual rhythm is.

What We Can Say ...

The QRS is narrow — and the rhythm in Figure-1 is almost regular at a ventricular rate of between 65-70/minute.

• Surprisingly tall and regular upright deflections are seen in the inferior leads throughout the tracing in Figure-1, with a consistent 4:1 ratio of 4 deflections for each QRS complex.
• P waves are nowhere to be seen (although P waves could certainly be hiding within any of the large deflections that we see throughout this tracing).
• These extra deflections that are so prominent in 5/6 limb leads — are tiny (barely visible) in lead aVL.
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• Impression: Although it might be tempting to consider AFlutter with 4:1 AV conduction — I thought this highly unlikely given the large amplitude of these extra deflections in 5/6 limb leads. 
• That said — I would want to see 2 things before passing final judgment on the rhythm diagnosis: i) What do the remaining 6 chest leads look like? — and, ii) What does the patient look like? (ie, Is there any device on or near the patient that might produce these fast extra deflections — or — is the patient doing anything unusual?).

The Remaining 6 Leads ...

In Figure-2 — I've now included the chest leads.

• Your thoughts? 

Figure-2: The complete 12-lead ECG. 

Answer:

The additional 6 chest leads support our suspicion of artifact.

• Of the 6 chest leads — it is lead V1 that sees atrial activity best. Yet the extra deflections are smallest in lead V1 compared to the other 5 chest leads. This would not be the case if the rhythm was AFlutter.
• I have never seen flutter waves as tall as we see them in these chest leads (ie, up to 15 mm tall! ).
• P.S.: One look at the patient confirmed that these huge chest lead deflections are indeed the result of artifact (ie, It turned out that this patient had a severe case of drug-induced Parkinsonism with a gross resultant tremor).

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Acknowledgment: My appreciation to Cardiology Notes (FB ECG site) for allowing me to use this tracing — and to Ahmed Marai (from Anbar, Iraq) for drawing my attention to this case.

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ADDENDUM:

To facilitate finding examples of Technical "Misadventures" (ie, Lead Reversals and examples of Artifact) — I've added the Tab shown in Figure-3 to the top of every page in this ECG Blog:

Figure-3: Where to find this LINK in the Top Menu on every page!