Mild chest pain with palpitations presentation

From the first look of it, the confusing irregular rhythm pointed towards atrial fibrillation for me but then why are there visible P waves which look more like atrial flutter saw tooth waves.




On close inspection however, there are visible p waves that precede QRS complexes. Sometimes, there are 2 or 3 P waves preceding each QRS complex. After seeing those combinations I noticed this complex distributed throughout the EKG and that's what made this atrial flutter with variable AV block. Meaning some of these P waves conduct through while others failed to do so. 

Additionally, I noticed these flutter waves to be particularly localized to inferior leads of II, III and aVF which makes this arrhythmia sort of localized in the inferior portion of the heart specifically right atrium. Such atrial flutter that is localized to the right atrium is usually due to cavotricuspid isthmus formation or CTI. 

If you notice in the image below. CTI is basically the main channel or predisposed area that gives rise to re-entrant atrial flutter or 'typical atrial flutter'. If the flutter waves are upward deviated or positive, the current flow is usually clock wise and negative deflected waves represent counterclock wise re-entrant flow. In my patient, the saw tooth waves are clearly positive which makes it clockwise re-entrant tachyarrhythmia.


Comments