22 Dec

Here’s an interesting 12-lead ECG and rhythm strip from a 66 yo male with dyspnea and a fever, with a yet undefined proces in the right lung.

Interpret en describe the ECG/rhythm strip.  More on this case will follow in two weeks.


ECG AFl 2 op 1 180 per minuut.1

ECG AFl 2 op 1 180 per minuut.2


So it’s a smalcomplex tachycardia (SCT) with a rate of 182/min; the axis is horizontal; There appear to be P-waves before every QRS with a PQ-time of 120 msec. But there also appears to be P-waves after each QRS (V2). QRS-width 70msec, QTc is calculated by the computer: 440msec. ST-segments are more difficult to describe due to the rate and the unsteady baseline.
Interpretation: The rate of approx 180/min in a SCT suggests an AV(N)RT. But the ‘P-waves’ after each QRS , which are exactly in the middle of the other P-waves, suggest an atrial flutter with 2:1 conduction, although classically the atrial flutter rate is approx 300/min resulting in a QRS-rate of 150/min in 2:1 conduction.
The cardiologists first reaction was it was probably a AVNRT, due to the rate. The cardiologist hadn’t seen the ECG (fax malfunctioned), so suggested Adenosine to convert or slow down the rhythm in case it would be a flutter (as vagal manoeuvres did nothing). And here’s what happend.

ECG right after Adenosine:

It’s important to realise, as we already know, that not everything goes by the book. The rate of an atrial flutter with a 2:1 conduction can at least vary from 90-180/min (by own experience). If the rate isn’t as it should be ‘by the book’ that doesn’t rule out a flutter. You have to keep an open mind and check the ECG in all leads, because some aspects (like the ‘P-waves’ in V2 in this ECG) will be seen in only one lead and can put you on the right track.

ECG AFl 2 op 1 180 per minuut met adenosine.3


5 Responses to “ECG”

  1. Ektor moon,MD December 22, 2013 at 16:01 #

    Hi Rene. Greetings from Venezuela. It looks as Atrial Flutter ,classical c 2 to 1 conduction.

  2. Laura December 23, 2013 at 11:13 #

    We think an atrial flutter 2:1 about 160/min. Its regular.
    However: our first thought was a re entry tachycardia because of the short PQ interval and delta-like waves in the anterolateral leads. But that doesn’t explain the p’s.

  3. reneverbeek December 24, 2013 at 23:55 #

    The heartrate is 182 bpm.

  4. Emil December 28, 2013 at 22:08 #

    Atrial tachycardia? Sinds the ‘p-waves’ are positive in aVR.

  5. lbkater December 29, 2013 at 22:52 #

    In the original post the answer from Rene

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