Tuesday, November 29, 2011

Atrial Flutter Mimicking ST Depression

A 65 year old presented with altered mental status and had an intracranial bleed:
One could be fooled into thinking this is sinus tachycardia (with a short PR interval) with diffuse ST depression.  But close inspection reveals flutter waves.  In particular, a totally upright p-wave in V1 is very unusual and should alert you to atrial flutter.  The fluttering baseline accounts for the apparent ST depression, although I cannot rule out some amount of true ischemic ST depression.

 Here is the ECG after cardioversion:
Now there is sinus.  Interestingly, this one also has an upright p-wave in V1 - so the rule is not universal!


  1. Dr. Smith,
    the P Wave in Sinus is really upright, but also in II, III there its somewhat biphasic and in aVR slight positiv, isnt it somewhat atypical for Sinus??

    1. Martin,
      good point. It is atypical.
      It's possibly a non-sinus atrial rhythm.


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