Atrial flutter differential diagnosis: Difference between revisions

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__NOTOC__
__NOTOC__
{{Atrial flutter}}
{{Atrial flutter}}
{{CMG}}; {{AE}} {{RT}}
{{CMG}}; {{AE}} {{RT}} {{HK}}


==Overview==
==Overview==
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! align="center" style="background:#4479BA; color: #FFFFFF;" + |Co-existing Conditions
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Co-existing Conditions
|-
|-
|Atrial Fibrillation<ref name="pmid24837984">{{cite journal |vauthors=Lankveld TA, Zeemering S, Crijns HJ, Schotten U |title=The ECG as a tool to determine atrial fibrillation complexity |journal=Heart |volume=100 |issue=14 |pages=1077–84 |date=July 2014 |pmid=24837984 |doi=10.1136/heartjnl-2013-305149 |url=}}</ref><ref name="pmid22518390">{{cite journal |vauthors=Harris K, Edwards D, Mant J |title=How can we best detect atrial fibrillation? |journal=J R Coll Physicians Edinb |volume=42 Suppl 18 |issue= |pages=5–22 |date=2012 |pmid=22518390 |doi=10.4997/JRCPE.2012.S02 |url=}}</ref>
|'''Atrial Fibrillation (AFib)<ref name="pmid24837984">{{cite journal |vauthors=Lankveld TA, Zeemering S, Crijns HJ, Schotten U |title=The ECG as a tool to determine atrial fibrillation complexity |journal=Heart |volume=100 |issue=14 |pages=1077–84 |date=July 2014 |pmid=24837984 |doi=10.1136/heartjnl-2013-305149 |url=}}</ref><ref name="pmid22518390">{{cite journal |vauthors=Harris K, Edwards D, Mant J |title=How can we best detect atrial fibrillation? |journal=J R Coll Physicians Edinb |volume=42 Suppl 18 |issue= |pages=5–22 |date=2012 |pmid=22518390 |doi=10.4997/JRCPE.2012.S02 |url=}}</ref>'''
|Irregularly irregular
|On a 10-second 12-lead EKG strip, multiply number of QRS complexes by 6
|Absent, fibrillatory waves
|Absent
|Less than 0.12 seconds, consistent, and normal in morphology in the absence of aberrant conduction
|Does not break with adenosine or vagal maneuvers
|
|
* 2.7–6.1 million people in the United States have AFib
*Irregularly irregular
* 2% of people younger than age 65 have AFib, while about 9% of people aged 65 years or older have AFib
|
|
* Old age
*On a 10-second 12-lead [[The electrocardiogram|EKG]] strip, multiply number of [[QRS complexes]] by 6
* Following bypass surgery
|
* Mitral valve disease
*Absent
* Hyperthyroidism
*Fibrillatory waves
* Diabetes
|
* Heart failure
*Absent
* Ischemic heart disease
|
* Chronic kidney disease
*Less than 0.12 seconds, consistent, and normal in morphology in the absence of aberrant conduction
* Heavy alcohol use
|
* Left chamber enlargement
*Does not break with [[adenosine]] or [[vagal maneuvers]]
|
*2.7–6.1 million people in the United States have AFib
*2% of people younger than age 65 have AFib, while about 9% of people aged 65 years or older have AFib
|
*Elderly
*Following [[Coronary artery bypass surgery|bypass surgery]]
*[[Mitral valve disease]]
*[[Hyperthyroidism]]
*[[Diabetes mellitus|Diabetes]]
*[[Heart failure]]
*[[Ischemic heart disease]]
*[[Chronic kidney disease]]
*Heavy [[alcohol]] use
*Left chamber enlargement
|-
|-
|Atrial Flutter
|'''[[Atrial Flutter]]'''<ref name="pmid28835836">{{cite journal |vauthors=Cosío FG |title=Atrial Flutter, Typical and Atypical: A Review |journal=Arrhythm Electrophysiol Rev |volume=6 |issue=2 |pages=55–62 |date=June 2017 |pmid=28835836 |pmc=5522718 |doi=10.15420/aer.2017.5.2 |url=}}</ref><ref name="BoyerKoplan2005">{{cite journal|last1=Boyer|first1=Melissa|last2=Koplan|first2=Bruce A.|title=Atrial Flutter|journal=Circulation|volume=112|issue=22|year=2005|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.105.540476}}</ref>
|Regular or Irregular
|
|75 (4:1 block), 100 (3:1 block) and 150 (2:1 block) bpm, but 150 is more common
*Regular or Irregular
|Sawtooth pattern of P waves at 250 to 350 beats per minute
|Varies depending upon the magnitude of the block, but is short
|Less than 0.12 seconds, consistent, and normal in morphology
|Conduction may vary in response to drugs and maneuvers dropping the rate from 150 to 100 or to 75 bpm
|
|
* Incidence: 88 per 100,000 individuals
*75 (4:1 block), 100 (3:1 block) and 150 (2:1 block) beats per minute (bpm), but 150 is more common
|
|
* More common in the elderly
*Sawtooth pattern of P waves at 250 to 350 bpm
*Alcohol
*Biphasic deflection in V1
|
*Varies depending upon the magnitude of the block, but is short
|
*Less than 0.12 seconds, consistent, and normal in morphology
|
*Conduction may vary in response to drugs and maneuvers dropping the rate from 150 to 100 or to 75 bpm
|
*[[Incidence]]: 88 per 100,000 individuals
|
*[[Elderly]]
*[[Alcohol]]
*[[Congestive heart failure]]
*[[Rheumatic disease|Rheumatic valve disease]]
*[[Congenital heart disease]]
*[[Emphysema]]
*[[Hypertension]]
|-
|-
|Atrioventricular nodal reentry tachycardia (AVNRT)<ref name="pmid27617092">{{cite journal |vauthors=Katritsis DG, Josephson ME |title=Classification, Electrophysiological Features and Therapy of Atrioventricular Nodal Reentrant Tachycardia |journal=Arrhythm Electrophysiol Rev |volume=5 |issue=2 |pages=130–5 |date=August 2016 |pmid=27617092 |pmc=5013176 |doi=10.15420/AER.2016.18.2 |url=}}</ref><ref name="pmid20458824">{{cite journal |vauthors=Letsas KP, Weber R, Siklody CH, Mihas CC, Stockinger J, Blum T, Kalusche D, Arentz T |title=Electrocardiographic differentiation of common type atrioventricular nodal reentrant tachycardia from atrioventricular reciprocating tachycardia via a concealed accessory pathway |journal=Acta Cardiol |volume=65 |issue=2 |pages=171–6 |date=April 2010 |pmid=20458824 |doi=10.2143/AC.65.2.2047050 |url=}}</ref>
|'''[[Atrioventricular nodal reentry tachycardia]] ([[AV nodal reentrant tachycardia|AVNRT]])<ref name="pmid27617092">{{cite journal |vauthors=Katritsis DG, Josephson ME |title=Classification, Electrophysiological Features and Therapy of Atrioventricular Nodal Reentrant Tachycardia |journal=Arrhythm Electrophysiol Rev |volume=5 |issue=2 |pages=130–5 |date=August 2016 |pmid=27617092 |pmc=5013176 |doi=10.15420/AER.2016.18.2 |url=}}</ref><ref name="pmid20458824">{{cite journal |vauthors=Letsas KP, Weber R, Siklody CH, Mihas CC, Stockinger J, Blum T, Kalusche D, Arentz T |title=Electrocardiographic differentiation of common type atrioventricular nodal reentrant tachycardia from atrioventricular reciprocating tachycardia via a concealed accessory pathway |journal=Acta Cardiol |volume=65 |issue=2 |pages=171–6 |date=April 2010 |pmid=20458824 |doi=10.2143/AC.65.2.2047050 |url=}}</ref>'''<ref name="urlAtrioventricular Nodal Reentry Tachycardia (AVNRT) - StatPearls - NCBI Bookshelf">{{cite web |url=https://www.ncbi.nlm.nih.gov/books/NBK499936/ |title=Atrioventricular Nodal Reentry Tachycardia (AVNRT) - StatPearls - NCBI Bookshelf |format= |work= |accessdate=}}</ref><ref name="pmid25196716">{{cite journal |vauthors=Schernthaner C, Danmayr F, Strohmer B |title=Coexistence of atrioventricular nodal reentrant tachycardia with other forms of arrhythmias |journal=Med Princ Pract |volume=23 |issue=6 |pages=543–50 |date=2014 |pmid=25196716 |pmc=5586929 |doi=10.1159/000365418 |url=}}</ref>
|
|
*Regular
|
|
|Inverted, superimposed on or buried within the QRS complex (pseudo R prime in V1/pseudo S wave in inferior leads)
*140-280 bpm
|Absent (P wave can appear after the QRS complex and before the T wave, and in atypical AVNRT, the P wave can appear just before the QRS complex)
|Less than 0.12 seconds, consistent, and normal in morphology in the absence of aberrant conduction, QRS alternans may be present
|May break with adenosine or vagal maneuvers
|60%-70% of all SVTs
|
|
*Slow-Fast AVNRT:
**Pseudo-S wave in leads II, III, and AVF
**Pseudo-R' in lead V1.
*Fast-Slow AVNRT
**[[P waves]] between the [[QRS complex|QRS]] and [[T waves]] (QRS-P-T complexes)
*Slow-Slow AVNRT
**Late [[P waves]] after a [[QRS complex|QRS]]
**Often appears as [[atrial tachycardia]].
*Inverted, superimposed on or buried within the [[QRS complex]] (pseudo R prime in V1/pseudo S wave in inferior leads)
|
*Absent ([[P wave]] can appear after the QRS complex and before the T wave, and in atypical AVNRT, the [[P wave]] can appear just before the [[QRS complex]])
|
*Less than 0.12 seconds, consistent, and normal in morphology in the absence of aberrant conduction
*[[QRS complex alternans|QRS alternans]] may be present
|
*May break with [[adenosine]] or [[vagal maneuvers]]
|
*60%-70% of all [[supraventricular tachycardias]]
|
*[[Structural heart disease]]
*[[Atrial tachyarrhythmias]]
|-
|-
|Multifocal Atrial Tachycardia<ref name="pmid2570520">{{cite journal |vauthors=Scher DL, Arsura EL |title=Multifocal atrial tachycardia: mechanisms, clinical correlates, and treatment |journal=Am. Heart J. |volume=118 |issue=3 |pages=574–80 |date=September 1989 |pmid=2570520 |doi=10.1016/0002-8703(89)90275-5 |url=}}</ref><ref name="pmid11884328">{{cite journal |vauthors=Goodacre S, Irons R |title=ABC of clinical electrocardiography: Atrial arrhythmias |journal=BMJ |volume=324 |issue=7337 |pages=594–7 |date=March 2002 |pmid=11884328 |pmc=1122515 |doi=10.1136/bmj.324.7337.594 |url=}}</ref>
|'''[[Multifocal atrial tachycardia|Multifocal Atrial Tachycardia]]<ref name="pmid2570520">{{cite journal |vauthors=Scher DL, Arsura EL |title=Multifocal atrial tachycardia: mechanisms, clinical correlates, and treatment |journal=Am. Heart J. |volume=118 |issue=3 |pages=574–80 |date=September 1989 |pmid=2570520 |doi=10.1016/0002-8703(89)90275-5 |url=}}</ref><ref name="pmid11884328">{{cite journal |vauthors=Goodacre S, Irons R |title=ABC of clinical electrocardiography: Atrial arrhythmias |journal=BMJ |volume=324 |issue=7337 |pages=594–7 |date=March 2002 |pmid=11884328 |pmc=1122515 |doi=10.1136/bmj.324.7337.594 |url=}}</ref>'''
|Irregular
|
|Atrial rate is > 100 beats per minute
*Irregular
|Varying morphology from at least three different foci, absence of one dominant atrial pacemaker, can be mistaken for atrial fibrillation if the P waves are of low amplitude
|
|Variable PR intervals, RR intervals, and PP intervals
*[[Atrial]] rate is > 100 beats per minute
|Less than 0.12 seconds, consistent, and normal in morphology
|
|Does not terminate with adenosine or vagal maneuvers
*Varying morphology from at least three different foci
*Absence of one dominant atrial pacemaker, can be mistaken for [[atrial fibrillation]] if the [[P waves]] are of low amplitude
|
*Variable [[PR interval|PR intervals]], RR intervals, and PP intervals
|
*Less than 0.12 seconds, consistent, and normal in morphology
|
*Does not terminate with [[adenosine]] or [[vagal maneuvers]]
|
*0.05% to 0.32% of [[electrocardiograms]] in general hospital admissions
|
|
|High incidence in the elderly and in those with COPD
*[[Elderly]]
*[[Chronic obstructive pulmonary disease]] ([[Chronic obstructive pulmonary disease|COPD]])
|-
|-
|Paroxysmal Supraventricular Tachycardia
|'''Paroxysmal Supraventricular Tachycardia'''
|
*Regular
|
|
* Regular
*150 and 240 bpm
|150 and 240 beats per minute
|
|
* Absent
*Absent
* Hidden in QRS
*Hidden in [[QRS complex|QRS]]
|
|
*Absent
|
|
* Narrow complexes
*Narrow complexes (< 0.12 s)
|
|
* Breaks with vagal maneuvers, adenosine, diving reflex, oculocardiac reflex
*Breaks with [[vagal maneuvers]], [[adenosine]], [[diving reflex]], [[oculocardiac reflex]]
|
|
* Prevalence: 0.023 per 100,000
*[[Prevalence]]: 0.023 per 100,000
|
|
* Alcohol
*[[Alcohol]]
* Caffeine
*[[Caffeine]]
* Nicotine
*[[Nicotine]]
* Psychological stress
*[[Psychological stress]]
* Wolff-Parkinson-White syndrome
*[[Wolff-Parkinson-White syndrome]]
|-
|-
|Wolff-Parkinson-White Syndrome<ref name="pmid24982705">{{cite journal |vauthors=Rao AL, Salerno JC, Asif IM, Drezner JA |title=Evaluation and management of wolff-Parkinson-white in athletes |journal=Sports Health |volume=6 |issue=4 |pages=326–32 |date=July 2014 |pmid=24982705 |pmc=4065555 |doi=10.1177/1941738113509059 |url=}}</ref><ref name="pmid10597097">{{cite journal |vauthors=Rosner MH, Brady WJ, Kefer MP, Martin ML |title=Electrocardiography in the patient with the Wolff-Parkinson-White syndrome: diagnostic and initial therapeutic issues |journal=Am J Emerg Med |volume=17 |issue=7 |pages=705–14 |date=November 1999 |pmid=10597097 |doi=10.1016/s0735-6757(99)90167-5 |url=}}</ref>
|'''[[Premature atrial contraction|Premature Atrial Contractrions]] ([[Premature atrial contraction|PAC]])'''<ref name="pmid26316525">{{cite journal |vauthors=Lin CY, Lin YJ, Chen YY, Chang SL, Lo LW, Chao TF, Chung FP, Hu YF, Chong E, Cheng HM, Tuan TC, Liao JN, Chiou CW, Huang JL, Chen SA |title=Prognostic Significance of Premature Atrial Complexes Burden in Prediction of Long-Term Outcome |journal=J Am Heart Assoc |volume=4 |issue=9 |pages=e002192 |date=August 2015 |pmid=26316525 |pmc=4599506 |doi=10.1161/JAHA.115.002192 |url=}}</ref><ref name="pmid18063110">{{cite journal |vauthors=Strasburger JF, Cheulkar B, Wichman HJ |title=Perinatal arrhythmias: diagnosis and management |journal=Clin Perinatol |volume=34 |issue=4 |pages=627–52, vii–viii |date=December 2007 |pmid=18063110 |pmc=3310372 |doi=10.1016/j.clp.2007.10.002 |url=}}</ref>
|Regular
|Atrial rate is nearly 300 bpm and ventricular rate is at 150 bpm
|With orthodromic conduction due to a bypass tract, the P wave generally follows the QRS complex, whereas in AVNRT, the P wave is generally buried in the QRS complex.
|Less than 0.12 seconds
|A delta wave and evidence of ventricular pre-excitation if there is conduction to the ventricle via ante-grade conduction down an accessory pathway. It should be noted, however, that in some patients with WPW, a delta wave and pre-excitation may not be present because bypass tracts do not conduct ante-grade.
|May break in response to procainamide, adenosine, vagal maneuvers
|Worldwide prevalence of WPW syndrome is 100 - 300 per 100,000
|
|
*Regular except when disturbed by premature beat(s)
|
*80-120 bpm
|
*Upright
|
*> 0.12 second
*May be shorter than that in normal sinus rhythm (NSR) if the origin of PAC is located closer to the AV node
*Ashman’s Phenomenon:
**[[Premature atrial contraction|PAC]] displaying a [[right bundle branch block]] pattern
|
*Usually narrow (< 0.12 s)
|
*Breaks with [[vagal maneuvers]], [[adenosine]], [[diving reflex]], [[oculocardiac reflex]]
|
|
*[[Infant|Infants]]
*[[Cardiomyopathy]]
*[[Myocarditis]]
*[[Elderly]]
*[[Coronary artery disease]]
*[[Stroke]]
*Increased [[atrial natriuretic peptide]] ([[Atrial natriuretic peptide|ANP]])
*[[Hypercholesterolemia]]
|-
|'''[[Wolff-Parkinson-White syndrome|Wolff-Parkinson-White Syndrome]]<ref name="pmid24982705">{{cite journal |vauthors=Rao AL, Salerno JC, Asif IM, Drezner JA |title=Evaluation and management of wolff-Parkinson-white in athletes |journal=Sports Health |volume=6 |issue=4 |pages=326–32 |date=July 2014 |pmid=24982705 |pmc=4065555 |doi=10.1177/1941738113509059 |url=}}</ref><ref name="pmid10597097">{{cite journal |vauthors=Rosner MH, Brady WJ, Kefer MP, Martin ML |title=Electrocardiography in the patient with the Wolff-Parkinson-White syndrome: diagnostic and initial therapeutic issues |journal=Am J Emerg Med |volume=17 |issue=7 |pages=705–14 |date=November 1999 |pmid=10597097 |doi=10.1016/s0735-6757(99)90167-5 |url=}}</ref>'''
|
*Regular
|
*Atrial rate is nearly 300 bpm and ventricular rate is at 150 bpm
|
*With [[orthodromic]] conduction due to a bypass tract, the [[P wave]] generally follows the [[QRS complex]], whereas in [[AVNRT]], the [[P wave]] is generally buried in the [[QRS complex]].
|
*Less than 0.12 seconds
|
*A [[delta wave]] and evidence of [[ventricular]] pre-excitation if there is conduction to the ventricle via ante-grade conduction down an accessory pathway
*A [[delta wave]] and pre-excitation may not be present because bypass tracts do not conduct ante-grade.
|
*May break in response to [[procainamide]], [[adenosine]], [[vagal maneuvers]]
|
*Worldwide [[prevalence]] of [[Wolff-Parkinson-White syndrome|WPW syndrome]] is 100 - 300 per 100,000
|
*[[Ebstein's anomaly]]
*[[Mitral valve prolapse]]: This cardiac disorder, if present, is associated with left-sided accessory pathways.
*[[Hypertrophic cardiomyopathy]]: This disorder is associated with familial/inherited form of [[Wolff-Parkinson-White syndrome|WPW syndrome]].
*[[Hypokalemic periodic paralysis]]
*[[Pompe disease]]
*[[Tuberous sclerosis]]
|-
|-
|Ventricular Fibrillation
|'''[[Ventricular fibrillation|Ventricular Fibrillation]] (VF)'''<ref name="pmid27899944">{{cite journal |vauthors=Glinge C, Sattler S, Jabbari R, Tfelt-Hansen J |title=Epidemiology and genetics of ventricular fibrillation during acute myocardial infarction |journal=J Geriatr Cardiol |volume=13 |issue=9 |pages=789–797 |date=September 2016 |pmid=27899944 |pmc=5122505 |doi=10.11909/j.issn.1671-5411.2016.09.006 |url=}}</ref><ref name="pmid11334828">{{cite journal |vauthors=Samie FH, Jalife J |title=Mechanisms underlying ventricular tachycardia and its transition to ventricular fibrillation in the structurally normal heart |journal=Cardiovasc. Res. |volume=50 |issue=2 |pages=242–50 |date=May 2001 |pmid=11334828 |doi=10.1016/s0008-6363(00)00289-3 |url=}}</ref><ref name="pmid20142817">{{cite journal |vauthors=Adabag AS, Luepker RV, Roger VL, Gersh BJ |title=Sudden cardiac death: epidemiology and risk factors |journal=Nat Rev Cardiol |volume=7 |issue=4 |pages=216–25 |date=April 2010 |pmid=20142817 |pmc=5014372 |doi=10.1038/nrcardio.2010.3 |url=}}</ref>
|Irregular
|
|150 to 500 bpm
*Irregular
|Absent
|
|Absent
*150 to 500 bpm
|Absent (R on T phenomenon in the setting of ischemia)
|
*Absent
|
*Absent
|
*Absent (R on T phenomenon in the setting of ischemia)
|
|
*Does not break in response to [[procainamide]], [[adenosine]], [[vagal maneuvers]]
|
|
|Myocardial ischemia / infarction,
*3-12% cases of [[acute myocardial infarction]] (AMI)
 
*Out of 356,500 out of hospital cardiac arrests, 23% have VF as initial rhythm
cardiomyopathy,
|
 
*[[Myocardial ischemia]] / [[Myocardial infarction|infarction]]
channelopathies e.g. Long QT (acquired / congenital),
*[[Cardiomyopathy]]
 
*Channelopathies e.g. Long QT (acquired / congenital)
aortic stenosis,
*Electrolyte abnormalities ([[hypokalemia]]/[[hyperkalemia]], [[hypomagnesemia]])
 
*[[Aortic stenosis]]
aortic dissection,
*[[Aortic dissection]]
 
*[[Myocarditis]]
myocarditis,
*[[Cardiac tamponade]]
 
*Blunt trauma (Commotio Cordis)
cardiac tamponade,
*[[Sepsis]]
 
*[[Hypothermia]]
blunt trauma (Commotio Cordis), sepsis, hypothermia, pneumothroax, seizures, stroke
*[[Pneumothorax]]
*[[Seizures]]
*[[Stroke]]
|-
|-
|Ventricular Tacycardia
|'''[[Ventricular tachycardia|Ventricular Tachycardia]]'''<ref name="pmid19252119">{{cite journal |vauthors=Koplan BA, Stevenson WG |title=Ventricular tachycardia and sudden cardiac death |journal=Mayo Clin. Proc. |volume=84 |issue=3 |pages=289–97 |date=March 2009 |pmid=19252119 |pmc=2664600 |doi=10.1016/S0025-6196(11)61149-X |url=}}</ref><ref name="pmid21505622">{{cite journal |vauthors=Levis JT |title=ECG Diagnosis: Monomorphic Ventricular Tachycardia |journal=Perm J |volume=15 |issue=1 |pages=65 |date=2011 |pmid=21505622 |pmc=3048638 |doi=10.7812/tpp/10-130 |url=}}</ref>
|Regular
|> 100 beats per minute
|
|
|Wide complex, QRS duration > 120 milliseconds
*Regular
|
*> 100 bpm (150-200 bpm common)
|
*Absent
|<br />
 
*Absent
*Initial [[R wave]] in V1, initial r > 40 ms in V1/V2, notched S in V1, initial R in aVR, lead II R wave peak time ≥50 ms, no RS in V1-V6, and atrioventricular dissociation
|
|
*Wide complex, [[QRS complex|QRS]] duration > 120 milliseconds
|
|
*Does not break in response to [[procainamide]], [[adenosine]], [[vagal maneuvers]]
|
|
* 5-10% of patients presenting with myocardial infarction
*5-10% of patients presenting with AMI
|
|
* Coronary artery disease
*[[Coronary artery disease]]
* Aortic stenosis
*[[Aortic stenosis]]
* Cardiomyopathy,
*[[Cardiomyopathy]]
* Electrolyte imbalances (e.g., hypokalemia, hypomagnesemia)
*[[Electrolyte imbalance|Electrolyte imbalances]] (e.g., [[hypokalemia]], [[hypomagnesemia]])
* Inherited channelopathies (e.g., long-QT syndrome),
*Inherited [[channelopathies]] (e.g., [[long-QT syndrome]])
* Catecholaminergic polymorphic ventricular tachycardia
*[[Catecholaminergic polymorphic ventricular tachycardia]]
* Arrhythmogenic right ventricular dysplasia
*[[Arrhythmogenic right ventricular dysplasia]]
* Myocardial infarction
*[[Myocardial infarction]]
*[[Torsades de pointes]] is a form of polymorphic VT that is often associated with a prolonged [[QT interval]]
|}
|}


Latest revision as of 00:46, 15 June 2021

Atrial flutter Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2] Syed Hassan A. Kazmi BSc, MD [3]

Overview

Atrial flutter should be differentiated from atrial fibrillation, multifocal atrial tachycardia, SVT and wide complex tachycardia. An electrocardiogram artifact from tremor also can be confused with atrial flutter.

Differentiating Atrial flutter from other Diseases


Arrhythmia Rhythm Rate P wave PR Interval QRS Complex Response to Maneuvers Epidemiology Co-existing Conditions
Atrial Fibrillation (AFib)[1][2]
  • Irregularly irregular
  • Absent
  • Fibrillatory waves
  • Absent
  • Less than 0.12 seconds, consistent, and normal in morphology in the absence of aberrant conduction
  • 2.7–6.1 million people in the United States have AFib
  • 2% of people younger than age 65 have AFib, while about 9% of people aged 65 years or older have AFib
Atrial Flutter[3][4]
  • Regular or Irregular
  • 75 (4:1 block), 100 (3:1 block) and 150 (2:1 block) beats per minute (bpm), but 150 is more common
  • Sawtooth pattern of P waves at 250 to 350 bpm
  • Biphasic deflection in V1
  • Varies depending upon the magnitude of the block, but is short
  • Less than 0.12 seconds, consistent, and normal in morphology
  • Conduction may vary in response to drugs and maneuvers dropping the rate from 150 to 100 or to 75 bpm
Atrioventricular nodal reentry tachycardia (AVNRT)[5][6][7][8]
  • Regular
  • 140-280 bpm
  • Slow-Fast AVNRT:
    • Pseudo-S wave in leads II, III, and AVF
    • Pseudo-R' in lead V1.
  • Fast-Slow AVNRT
  • Slow-Slow AVNRT
  • Inverted, superimposed on or buried within the QRS complex (pseudo R prime in V1/pseudo S wave in inferior leads)
  • Absent (P wave can appear after the QRS complex and before the T wave, and in atypical AVNRT, the P wave can appear just before the QRS complex)
  • Less than 0.12 seconds, consistent, and normal in morphology in the absence of aberrant conduction
  • QRS alternans may be present
Multifocal Atrial Tachycardia[9][10]
  • Irregular
  • Atrial rate is > 100 beats per minute
  • Varying morphology from at least three different foci
  • Absence of one dominant atrial pacemaker, can be mistaken for atrial fibrillation if the P waves are of low amplitude
  • Less than 0.12 seconds, consistent, and normal in morphology
Paroxysmal Supraventricular Tachycardia
  • Regular
  • 150 and 240 bpm
  • Absent
  • Hidden in QRS
  • Absent
  • Narrow complexes (< 0.12 s)
Premature Atrial Contractrions (PAC)[11][12]
  • Regular except when disturbed by premature beat(s)
  • 80-120 bpm
  • Upright
  • > 0.12 second
  • May be shorter than that in normal sinus rhythm (NSR) if the origin of PAC is located closer to the AV node
  • Ashman’s Phenomenon:
  • Usually narrow (< 0.12 s)
Wolff-Parkinson-White Syndrome[13][14]
  • Regular
  • Atrial rate is nearly 300 bpm and ventricular rate is at 150 bpm
  • Less than 0.12 seconds
  • A delta wave and evidence of ventricular pre-excitation if there is conduction to the ventricle via ante-grade conduction down an accessory pathway
  • A delta wave and pre-excitation may not be present because bypass tracts do not conduct ante-grade.
Ventricular Fibrillation (VF)[15][16][17]
  • Irregular
  • 150 to 500 bpm
  • Absent
  • Absent
  • Absent (R on T phenomenon in the setting of ischemia)
Ventricular Tachycardia[18][19]
  • Regular
  • > 100 bpm (150-200 bpm common)
  • Absent
  • Absent
  • Initial R wave in V1, initial r > 40 ms in V1/V2, notched S in V1, initial R in aVR, lead II R wave peak time ≥50 ms, no RS in V1-V6, and atrioventricular dissociation
  • Wide complex, QRS duration > 120 milliseconds
  • 5-10% of patients presenting with AMI

References

  1. ↑ Lankveld TA, Zeemering S, Crijns HJ, Schotten U (July 2014). "The ECG as a tool to determine atrial fibrillation complexity". Heart. 100 (14): 1077–84. doi:10.1136/heartjnl-2013-305149. PMID 24837984.
  2. ↑ Harris K, Edwards D, Mant J (2012). "How can we best detect atrial fibrillation?". J R Coll Physicians Edinb. 42 Suppl 18: 5–22. doi:10.4997/JRCPE.2012.S02. PMID 22518390.
  3. ↑ Cosío FG (June 2017). "Atrial Flutter, Typical and Atypical: A Review". Arrhythm Electrophysiol Rev. 6 (2): 55–62. doi:10.15420/aer.2017.5.2. PMC 5522718. PMID 28835836.
  4. ↑ Boyer, Melissa; Koplan, Bruce A. (2005). "Atrial Flutter". Circulation. 112 (22). doi:10.1161/CIRCULATIONAHA.105.540476. ISSN 0009-7322.
  5. ↑ Katritsis DG, Josephson ME (August 2016). "Classification, Electrophysiological Features and Therapy of Atrioventricular Nodal Reentrant Tachycardia". Arrhythm Electrophysiol Rev. 5 (2): 130–5. doi:10.15420/AER.2016.18.2. PMC 5013176. PMID 27617092.
  6. ↑ Letsas KP, Weber R, Siklody CH, Mihas CC, Stockinger J, Blum T, Kalusche D, Arentz T (April 2010). "Electrocardiographic differentiation of common type atrioventricular nodal reentrant tachycardia from atrioventricular reciprocating tachycardia via a concealed accessory pathway". Acta Cardiol. 65 (2): 171–6. doi:10.2143/AC.65.2.2047050. PMID 20458824.
  7. ↑ "Atrioventricular Nodal Reentry Tachycardia (AVNRT) - StatPearls - NCBI Bookshelf".
  8. ↑ Schernthaner C, Danmayr F, Strohmer B (2014). "Coexistence of atrioventricular nodal reentrant tachycardia with other forms of arrhythmias". Med Princ Pract. 23 (6): 543–50. doi:10.1159/000365418. PMC 5586929. PMID 25196716.
  9. ↑ Scher DL, Arsura EL (September 1989). "Multifocal atrial tachycardia: mechanisms, clinical correlates, and treatment". Am. Heart J. 118 (3): 574–80. doi:10.1016/0002-8703(89)90275-5. PMID 2570520.
  10. ↑ Goodacre S, Irons R (March 2002). "ABC of clinical electrocardiography: Atrial arrhythmias". BMJ. 324 (7337): 594–7. doi:10.1136/bmj.324.7337.594. PMC 1122515. PMID 11884328.
  11. ↑ Lin CY, Lin YJ, Chen YY, Chang SL, Lo LW, Chao TF, Chung FP, Hu YF, Chong E, Cheng HM, Tuan TC, Liao JN, Chiou CW, Huang JL, Chen SA (August 2015). "Prognostic Significance of Premature Atrial Complexes Burden in Prediction of Long-Term Outcome". J Am Heart Assoc. 4 (9): e002192. doi:10.1161/JAHA.115.002192. PMC 4599506. PMID 26316525.
  12. ↑ Strasburger JF, Cheulkar B, Wichman HJ (December 2007). "Perinatal arrhythmias: diagnosis and management". Clin Perinatol. 34 (4): 627–52, vii–viii. doi:10.1016/j.clp.2007.10.002. PMC 3310372. PMID 18063110.
  13. ↑ Rao AL, Salerno JC, Asif IM, Drezner JA (July 2014). "Evaluation and management of wolff-Parkinson-white in athletes". Sports Health. 6 (4): 326–32. doi:10.1177/1941738113509059. PMC 4065555. PMID 24982705.
  14. ↑ Rosner MH, Brady WJ, Kefer MP, Martin ML (November 1999). "Electrocardiography in the patient with the Wolff-Parkinson-White syndrome: diagnostic and initial therapeutic issues". Am J Emerg Med. 17 (7): 705–14. doi:10.1016/s0735-6757(99)90167-5. PMID 10597097.
  15. ↑ Glinge C, Sattler S, Jabbari R, Tfelt-Hansen J (September 2016). "Epidemiology and genetics of ventricular fibrillation during acute myocardial infarction". J Geriatr Cardiol. 13 (9): 789–797. doi:10.11909/j.issn.1671-5411.2016.09.006. PMC 5122505. PMID 27899944.
  16. ↑ Samie FH, Jalife J (May 2001). "Mechanisms underlying ventricular tachycardia and its transition to ventricular fibrillation in the structurally normal heart". Cardiovasc. Res. 50 (2): 242–50. doi:10.1016/s0008-6363(00)00289-3. PMID 11334828.
  17. ↑ Adabag AS, Luepker RV, Roger VL, Gersh BJ (April 2010). "Sudden cardiac death: epidemiology and risk factors". Nat Rev Cardiol. 7 (4): 216–25. doi:10.1038/nrcardio.2010.3. PMC 5014372. PMID 20142817.
  18. ↑ Koplan BA, Stevenson WG (March 2009). "Ventricular tachycardia and sudden cardiac death". Mayo Clin. Proc. 84 (3): 289–97. doi:10.1016/S0025-6196(11)61149-X. PMC 2664600. PMID 19252119.
  19. ↑ Levis JT (2011). "ECG Diagnosis: Monomorphic Ventricular Tachycardia". Perm J. 15 (1): 65. doi:10.7812/tpp/10-130. PMC 3048638. PMID 21505622.

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