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==Differentiating Atrial flutter from other Diseases==
==Differentiating Atrial flutter from other Diseases==
<br />
{| class="wikitable"
|+
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Arrhythmia
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Rhythm
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Rate
! align="center" style="background:#4479BA; color: #FFFFFF;" + |P wave
! align="center" style="background:#4479BA; color: #FFFFFF;" + |PR Interval
! align="center" style="background:#4479BA; color: #FFFFFF;" + |QRS Complex
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Response to Maneuvers
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Epidemiology
! 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>
|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
* 2% of people younger than age 65 have AFib, while about 9% of people aged 65 years or older have AFib
|
* Old age
* Following bypass surgery
* Mitral valve disease
* Hyperthyroidism
* Diabetes
* Heart failure
* Ischemic heart disease
* Chronic kidney disease
* Heavy alcohol use
* Left chamber enlargement
|-
|Atrial Flutter
|Regular or Irregular
|75 (4:1 block), 100 (3:1 block) and 150 (2:1 block) bpm, but 150 is more common
|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
|
* More common in the elderly
*Alcohol
|-
|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>
|
|
|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
|May break with adenosine or vagal maneuvers
|60%-70% of all SVTs
|
|-
|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
|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
|Less than 0.12 seconds, consistent, and normal in morphology
|Does not terminate with adenosine or vagal maneuvers
|
|High incidence in the elderly and in those with COPD
|-
|Paroxysmal Supraventricular Tachycardia
|
* Regular
|150 and 240 beats per minute
|
* Absent
* Hidden in QRS
|
|
* Narrow complexes
|
* Breaks with vagal maneuvers, adenosine, diving reflex, oculocardiac reflex
|
* Prevalence: 0.023 per 100,000
|
* Alcohol
* Caffeine
* Nicotine
* Psychological stress
* 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. 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
|
|-
|Ventricular Fibrillation
|Irregular
|150 to 500 bpm
|Absent
|Absent
|Absent (R on T phenomenon in the setting of ischemia)
|
|
|Myocardial ischemia / infarction,


cardiomyopathy,
channelopathies e.g. Long QT (acquired / congenital),
aortic stenosis,
aortic dissection,
myocarditis,
cardiac tamponade,
blunt trauma (Commotio Cordis), sepsis, hypothermia, pneumothroax, seizures, stroke
|-
|Ventricular Tacycardia
|Regular
|> 100 beats per minute
|
|Wide complex, QRS duration > 120 milliseconds
|
|
|
* 5-10% of patients presenting with myocardial infarction
|
* Coronary artery disease
* Aortic stenosis
* Cardiomyopathy,
* Electrolyte imbalances (e.g., hypokalemia, hypomagnesemia)
* Inherited channelopathies (e.g., long-QT syndrome),
* Catecholaminergic polymorphic ventricular tachycardia
* Arrhythmogenic right ventricular dysplasia
* Myocardial infarction
|}


==References==
==References==

Revision as of 15:56, 9 December 2019

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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]

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[1][2] 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
  • 2% of people younger than age 65 have AFib, while about 9% of people aged 65 years or older have AFib
  • Old age
  • Following bypass surgery
  • Mitral valve disease
  • Hyperthyroidism
  • Diabetes
  • Heart failure
  • Ischemic heart disease
  • Chronic kidney disease
  • Heavy alcohol use
  • Left chamber enlargement
Atrial Flutter Regular or Irregular 75 (4:1 block), 100 (3:1 block) and 150 (2:1 block) bpm, but 150 is more common 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
  • More common in the elderly
  • Alcohol
Atrioventricular nodal reentry tachycardia (AVNRT)[3][4] 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 May break with adenosine or vagal maneuvers 60%-70% of all SVTs
Multifocal Atrial Tachycardia[5][6] 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 Variable 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 High incidence in the elderly and in those with COPD
Paroxysmal Supraventricular Tachycardia
  • Regular
 150 and 240 beats per minute
  • Absent
  • Hidden in QRS
  • Narrow complexes
  • Breaks with vagal maneuvers, adenosine, diving reflex, oculocardiac reflex
  • Prevalence: 0.023 per 100,000
  • Alcohol
  • Caffeine
  • Nicotine
  • Psychological stress
  • Wolff-Parkinson-White syndrome
Wolff-Parkinson-White Syndrome[7][8] 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
Ventricular Fibrillation Irregular 150 to 500 bpm Absent Absent Absent (R on T phenomenon in the setting of ischemia) Myocardial ischemia / infarction,

cardiomyopathy,

channelopathies e.g. Long QT (acquired / congenital),

aortic stenosis,

aortic dissection,

myocarditis,

cardiac tamponade,

blunt trauma (Commotio Cordis), sepsis, hypothermia, pneumothroax, seizures, stroke

Ventricular Tacycardia Regular > 100 beats per minute Wide complex, QRS duration > 120 milliseconds
  • 5-10% of patients presenting with myocardial infarction
  • Coronary artery disease
  • Aortic stenosis
  • Cardiomyopathy,
  • Electrolyte imbalances (e.g., hypokalemia, hypomagnesemia)
  • Inherited channelopathies (e.g., long-QT syndrome),
  • Catecholaminergic polymorphic ventricular tachycardia
  • Arrhythmogenic right ventricular dysplasia
  • Myocardial infarction

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. ↑ 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.
  4. ↑ 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.
  5. ↑ 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.
  6. ↑ 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.
  7. ↑ 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.
  8. ↑ 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.

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