Friday, June 22, 2012

What is the Diagnosis?

This 65 year old woman presented in cardiogenic shock:

Some will find this easy (if so, sorry!), but some might be confused.  See below.

Well, 2 cardiologists and one emergency physician thought that there was high lateral ST elevation with reciprocal ST depression in inferior leads.  They did not see that it was atrial flutter.  When you are tuned into reading atrial flutter, though, as I am, this is regognizable within seconds as atrial flutter.  The flutter waves distort the baseline and can make it appear to have ST elevation or depression.

Diagnosis: Atrial flutter.   There is no ST elevation or depression, only flutter waves that mimic ST deviation.

There was very poor LV function causing the shock, but made worse by poor filling due to atrial flutter with 2:1 block and a ventricular rate of 130.

The angiogram was completely normal.


  1. Is it ok to diagnose the LAFB when the underlying pattern is A-flutter?

    1. Yes, indeed. And there is LAFB here, as you noticed.

  2. Dr. Smith,

    When you say that when you are in tune into reading atrial flutter; what do you look for?

    1. Look for:
      1. Regular rhythm or
      1a. regularly irregular rhythm (all ventricular beats are a multiple of the flutter rate, 2:1 mixing with 3:1 and 4:1)

      2. ventricular Rate 125-170

      3. Wavy baseline in leads II and V1 especially

      4. Upright p-waves in lead V1

      5. Constant rate over time

      6. Can test with adenosine (blocks ventricular QRS and unmasks flutter waves.

  3. I find atrial flutter difficult to diagnose in ED specially 2:1

    1. It takes practice and, mostly, awareness to ask yourself, "Is this atrial flutter?"

  4. From my QI research in my ED, I can safely say that atrial flutter is one of the most common causes of a false positive interpretation of Acute MI by the Marquette 12SL algorithm.

  5. Saw the atrial flutter( pun intended), but had this as a LM critical stenosis with atrial flutter. WIth the seeming ST elevation aVR, V1 and aVL, and globlal ST depression.
    Thanks for the post as this will help to temper my reading of the ST segment in the setting of A Flutter.

  6. Since there is Left Axis Deviation, is it safe to say there is a possible LBBB and LAFB as well?

  7. Good point about LAFB. Yes. But there is no LBBB and, if there were, you would not see LAFB because LBBB = both LAFB and LPFB.


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