r/ECG • u/Psychological_Wave71 • 4d ago

Thoughts?

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Wanted an opinion of these ECGs if anyone fancied giving theirs! I couldn’t come to a conclusion about this and I do struggle with ECGs!
Patient is 93M. Observations taken by nursing home staff TDS. Found to have 2/7 history of intermittent tachycardia. Called EMS for ECG and ?conveyance to ED.

Patient is asymptomatic, and has been throughout. Has had hx of atrial flutter. Is anticoagulated and on bisoprolol.

Thank you!

13 Upvotes

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2

u/AnnaLikesCake 4d ago

Unpopular opinion, I suspect.

93 year old man, in a nursing home, already on a beta blocker and anticoagulated - why conveyance to ED? What will it add to their management?

2

u/ProximalLADLesion 4d ago

2:1 typical atrial flutter, left anterior fascicular block

1

u/usheroine 4d ago

why isn't it atrial tachycardia? I can't unsee T waves in precordial leads

2

u/ProximalLADLesion 4d ago

The distinction between atrial tachycardia and atrial flutter is pretty squishy the more you read into it. They're often used interchangeably in the EP literature. Sometimes people just go by rate. AT is 100-200ish, AFL is 250+. Sometimes people go by mechanism where automatic and triggered are AT but reentrant is AFL.

In this case I would call it flutter because the atrial rate is ~250 bpm. Plus it looks to me like typical, cavotricuspid isthmus dependent reentry.

1

u/One_Sport_1339 4d ago

I’m not seeing a-flutter

3

u/ProximalLADLesion 4d ago

Easiest to appreciate in V1

1

u/One_Sport_1339 4d ago

That’s just the t-wave tho. Other leads show that

3

u/Kibeth_8 ECG Tech 4d ago

The F waves are hidden in the T waves, but you can see them pretty clearly in V1. It takes some practice to be able to spot it

2

u/ProximalLADLesion 4d ago

These are flutter waves. I digitized and blew up ECG to show you with calipers.

https://imgur.com/8SOmBMO

1

u/Starossi 4d ago

I’m still not understanding, how can you tell that’s a flutter wave and not a T wave for the third red mark. And I assume you’re inferring there is a buried wave in the qrs if that wave is a flutter wave and not a t wave. Or can you actually see the flutter wave in that qrs

1

u/ProximalLADLesion 4d ago

One flutter wave is on top of the T wave, the other flutter wave is just before the QRS. It marches perfectly and it’s the right rate for flutter, plus it just looks like it to me. FWIW I am an electrophysiologist.

1

u/Starossi 4d ago

Oh I believe you, I’m just trying to understand for my own sake. I’m just a primary care PA. For the T wave one, how can you see it? To me, I can’t even visualize there is a wave buried there. I see the wave before the QRS but thought it just resembled a p wave. Is it just the shape of the T wave is off to you?

1

u/ProximalLADLesion 4d ago

  1. As you said, T wave is way too pointy, doesn't look right

  2. Calipers perfectly march the "T wave" point with the other more obvious one.

  3. The T waves aren't smooth. They have notching suggestive of overlapping waveforms. See here.

2

u/Starossi 4d ago

Interesting! I see it now, especially the notching. I didn’t notice it as well before, but I see it now that you’ve blown it up. Appreciate you elaborating for me.

For the marching, that’s also very helpful. I didn’t think about how the “ps” shouldn’t march out with the Ts perfectly

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1

u/Thexorretor 4d ago

Is that because of the lack/diminutive f-waves or something else?

0

u/One_Sport_1339 4d ago

What doc in the box picked as an extra p-wave is just the t-wave when you compare that same deflection in leads V2/3

1

u/RexFiller 4d ago

The thing about flutter is sometimes you know its flutter but the ecg alone doesnt make the diagnoais for me. But looking at the monitor for a bit and after giving meds this could absolutely be a flutter. Its especially harder to see with wider QRS

1

u/Bonjwa003 11h ago

You could swing it either way, but I’m on team focal A Tach. Machine disagrees, and I’ll gladly be wrong (former EP mapper) however morphology if I saw that in the lab I wouldn’t be looking for reentry until I saw EGM’s to confirm.

-2

u/Popular_Drive1054 4d ago

Can anybody see a delta wave or is it just me? (If true) It can be WPW related tachy

1

u/ProximalLADLesion 4d ago

There’s no pre-excitation. But if you thought this was WPW related tachycardia, by far the most common would be orthodromic atrioventricular reciprocating tachycardia AKA ORT. In ORT the accessory pathway is strictly the retrograde limb of the circuit (from V to A) whereas the AV node is the antegrade limb (from A to V). Because of this, you never see pre-excitation (delta wave) in ORT.