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Dr A Röschl's picture

Atrial Flutter With Right Bundle Branch Block and Left Anterior Fascicular Block In a Patient With Preexisting RBBB + LAFB

Submitted by Dr A Röschl on Mon, 12/18/2023 - 11:14

If a wide complex tachycardia occurs, the probability is very high that it is a ventricular tachycardia (approx. 80%, in patients with a previous myocardial infarction (...) approx. 90%). Here we see a broad complex tachycardia that looks like an RBBB + LAFB, which is regular. In this constellation, 3 causes must be considered:
1. fascicular tachycardia from the left posterior fascicle of the left tawara fascicle (QRS width usually only around 130 ms, but sometimes significantly longer).
2. AT/AFL with 2:1 conduction in the case of pre-existing bifascicular block

Dawn's picture

ECG Basics: Atrial Flutter With 2:1 Conduction And An Aberrantly-conducted Beat

Submitted by Dawn on Sun, 08/23/2015 - 12:20

This strip was taken from a patient at rest.  It shows a regular tachycardia with a slightly-widened QRS complex at about .10 seconds duration.  It is somewhat difficult to evaluate the baseline for P waves or flutter waves.  We ALWAYS recommend multi-lead assessment for such evaluation.  The P waves (or flutter waves) here have a sharp point, and can be easily "marched out", with a rate of about 300 per minute.

Whenever the ventricular rate is near 150/min., we should always consider the possibility of atrial flutter with 2:1 conduction.  Since atrial flutter results in atrial depolarization at around 250 - 350 per minute, conducting every other P wave results in a rate of about 150.  It can masquerade as sinus tach, but a patient with sinus tach at such a fast rate would probably have an obvious cause for a rapid heart rate, such as hypovolemia, drug overdose, or exertion.  This rhythm could also be mistaken for atrial tachycardia or other forms of supraventricular tachycardia (SVT, PSVT, AVNRT, etc.).   Multiple leads can more easily uncover the flutter waves running continuously "behind" and "through" the QRS complexes.

There is one beat that is obviously different from the others.  This beat is about the same width as the other QRS complexes, but is opposite in direction.  This probably represents aberrant conduction, possibly a hemiblock that occurs only in this beat.  Careful measurement will show that this QRS is very slightly early, while the others are all very regular. The slight width of all the QRS complexes suggests that there is a conduction delay, which cannot be diagnosed on one strip with no patient history available.

There are other differential diagnoses, such as ventricular tachycardia with a captured sinus beat.  We welcome discussion of this interesting strip. 

Dawn's picture

ECG Basics: Atrial Flutter With 2:1 Conduction Ratio, Rhythm strip

Submitted by Dawn on Thu, 07/17/2014 - 15:40

One of the most frequently misdiagnosed rhythms, atrial flutter with 2:1 conduction often masquerades as sinus tach.  Sinus tach usually has an obvious cause, such as exercise, severe hypovolemia, or age less than 6 months.  Atrial flutter usually produces flutter waves (P waves) at a rate of 250 - 350 per minute.  Therefore, a 2:1 conduction ratio would result in a heart rate of about 125 - 175 bpm).  

Often, students are taught about atrial flutter using an electronic rhythm generator or a book with limited illustrations, and they become acustomed to seeing atrial flutter with 3:1 or 4:1 conduction.  The flutter waves are very easy to see in such a situation.  However, the AV node, if not affected by medication, is usually well able to conduct at a rate of 150 or more.  Therefore, the physiological block that protects us from extreme rates will keep the heart rate around 150 bpm in atrial flutter.

This is a single rhythm strip.  It can be VERY helpful to look at multiple leads to look for flutter waves.  See this week's Instructors' Collection ECG of the WEEK for the SAME patient's 12-Lead ECG.  Also, your students should be reminded that sinus rhythms, including sinus tach, tend to change rates based on the needs of the patient.  For example, as a patient is treated for his/her condition, the rate may improve by slowing.  Conversely, if the condition becomes worse, or the patient is stressed, the rate may increase.  Atrial flutter, like all re-entry tachycardias, tends to stay at a steady rate unless the conduction ratio changes.

Show your students that the flutter waves are CONTINUOUS.  That is, they don't pause for the QRS.  The second illustration shows the flutter waves highlighted, to aid in seeing the continuous line of flutter waves.

Dawn's picture

Atrial Flutter With 2:1 Conduction

Submitted by Dawn on Thu, 07/17/2014 - 14:32

One of the most frequently misdiagnosed rhythms, atrial flutter with 2:1 conduction often masquerades as sinus tach.  Sinus tach usually has an obvious cause, such as exercise, severe hypovolemia, or age less than 6 months.  Atrial flutter usually produces flutter waves (P waves) at a rate of 250 - 350 per minute.  Therefore, a 2:1 conduction ratio would result in a heart rate of about 125 - 175 bpm).  Often, students are taught about atrial flutter using an electronic rhythm generator or a book with limited illustrations, and they become acustomed to seeing atrial flutter with 3:1 or 4:1 conduction.  The flutter waves are very easy to see in such a situation.  However, the AV node, if not affected by medication, is usually well able to conduct at a rate of 150 or more.  Therefore, the physiological block that protects us from extreme rates will keep the heart rate around 150 bpm in atrial flutter.

This ECG shows two instances where the conduction ratio slows to 3:1 momentarily, at beats no. 3 and 20.  This makes the atrial flutter more apparent.  Students should be taught to check multiple leads in any patient with a heart rate of between 125 bpm and 175 bpm, and look for flutter waves.  Flutter waves are continuous - they do not "pause" for the QRS.  For a rhythm strip with the flutter waves highlighted, see this patient's rhythm strip.

 

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