Atrial Flutter

I had flutter diagnosed only once, but I am a formally diagnosed AF patient, now free of AF for three years after two catheter ablations, RF energy, not the newer pulsed field ablation (PFA).

Flutter is hard to see on a normal ECG. In my case, the attending asked me if I would accept a dose of adenosine, explaining it would slow my heart, but not change my rhythm. It's a dreadful sensation when they inject it, but I was promised it would fade inside of 15 seconds, and they were spot on. So, the adenosine slows that heart and the attending immediately pointed to the monitor behind me and said, 'See? Flutter.

One of the leads should show an obvious sawtooth wave, sharp and regular....because it is normal sinus, just fast. Too fast. For AF, on the other hand, your Kardia would show two clear indicators: no P-wave, the small blip before that major squiggle that is the QRS complex. That P-wave is the depoloarization of the atrium at which it contracts. It's repolarization wave is 'buried' somewhere in the extreme QRS. Second indicator is that the peak-to-peak timing between the R-waves is all over the place...some long, some short, and no rhythm to speak of...what cardiologists term 'irregularly irregular'. Agan, your Kardia would know if it's AF and so would you if you have a decent graphic depiction on which to base your assessments.

If a wearable/smart watch or your Kardia says something like, 'unknown, possible AF, or undetermined', then it probably is not AF and could be PACs, premature atrial complexes, or SVT, or flutter.

The bark is worse than the bite in the case of SVT, PACs, and AF. They're not generally dangerous, not right away, and usually respond to treatment. What you would most certainly not do is to ignore a high pulse rate of 100+ indicated that lasts without a sizeable break for 24 hours. If this happens, tachyarrhythmia of any kind lasting for 24 hours, get to Emerg and get some attention.

Thank you for the very detailed explanation of how to read an EKG.

@gloaming
Thanks you for the your feed back. I actually sent my EKG to Kardia to be interpreted Their reply was SVT with no secondary observations. It's quite a nifty device. Kardia, for those are unfamiliar with it. I've reviewed a number of examples on the Internet for Arial Flutter none of them match what my EKG looks like no "saw tooth" waves in any lead. The final comment from the EP doc was he couldn't "rule out" atrial flutter but he also said he couldn't or wouldn't interpret the Kardia EKG readings. I suppose he thinks they undiagnostic?

@heartache The Kardia 6L is a pretty nifty device for the price, but it is a poor substitute for a proper 6 lead ECG and it isn't a 12 lead, which the cardio/EP team would want in order to get a definitive diagnosis. The EP I went to did my index ablation, but I was in the ICU six whole days later and shortly put on amiodarone because my heart was in a nasty chaotic arrhythmia. I went through the ten week blanking period, where the heart calms and all the multiple lesions heal up to scar tissue, and then comes the Holter monitor worn for about a day or less. In my case, my Holter showed a lot of PACs, not a good sign. About six weeks later, I broke into AF again, but this time I made my Samsung Galaxy watch take an ECG. I uploaded the file to my PC from my phone's controlling health app, and sent it to his nurse. He immediately accepted the Galaxy's assessment and agreed I had recurrent AF, and scheduled me for an ablation three months later. So, while the wearables are by no means foolproof, or even very reliably accurate, they can indicate a potential problem and the conscientious EP or cardiologist should invite you in for a proper 12 lead assessment. In my case, he didn't want to see me....he believed my watch's depiction which was my typical chaotic rhythm, no obvious P-waves before each QRS, and the peak-to-peaks were very obviously variable. He could hardly argue. 😀

The drift i picked up on was the first interventual cardiologist I saw probably was not certain what type of SVT was being indicated. I did tell him on one occasion I tried a Vagal Maneuver with Ice pack on my face and the arrhythmia did stop with a reply from him was "sounds like the standard SVT" . He probably thought he would pass me along to the EP doc to cover all the bases making a statement "I think I might see a wave in the EKG readings " . The EP doc was not going to diagnose me based on a Kardia EKG readout. Perhaps because of heart rate around 150 bpm it could be Atrial Flutter (300 bpm) with 2:1 block basically the ventricles cannot keep up with the atrial flutter rate so you get 150 bpm. Having worked in periphery of medical industry being a field service Engineer for Cardio Vascular and Special procedure rooms I'm a bit skeptical of what I'm being told. Sounds like your outcome with your issues is good one glad to hear the Ablations were successful.

I’m a failed pfa pulmonary ablation and now am in a similar position. I’ve been having svt, now usually resistant to vagal maneuvers including the sitting valsalva for 30 seconds followed by the leg pop up in the air with the exhale, that is followed by afib. A few days ago I was on hour 12 of afib when I went into a steady 100 bpm rhythm with more shortness of breath than afib. I didn’t see a sawtooth on my Kardia 6 lead. It was reading it as sinus tachycardia. By hour 16 I was feeling worse so I went to the ER. By then I was back in a fib. I was monitored for another 24 hours and was flipping between flutter and fib. I never had the classic 150 bpm sawtooth ecg. I eventually converted after a rough 36 hours. I had another svt induced afib last night but didn’t get flutter. I didn’t take my usual pill in the pocket flecainide, I just took metoprolol 50 mg. I’m wondering if flecainide is making my flutter more likely. I am supposed to get my 2nd ablation in August. Ugh. I hate flutter more than a fib now. Flecanide used to work. My resting heart is about 48 so chronic metoprolol is a challenge. Flutter can be hard to diagnose. Usually the source is around the tricuspid valve. You need a good mapping for the ablation and PFA isn’t as good as radio frequency for the spots where flutter triggers are usually found.

@diane987654321 I've tried Vagal maneuvers but the only instruction I've had on performing them is on the Internet. When i saw the EP doc he was telling me about Carotid massage that seems to help in a lot of cases. I have deep veins so my carotid pulse (neck area) is hard to find even had my wife try to find it but she couldn't. So far diltiazem has seemed to have stopped the episodes of SVT but I'm sure in time as I age it will get worse. I used to be field engineer that serviced Xray equipment used in Cardiac Cath Labs. A lot process has been made when it comes to treatment Coronary Artery Disease i was involved in image quality for physicians to view the blockages. The technology has vastly improved but Heart Arrhythmia treatment technology has had a slower process in development I think however that's also changing. There are now dedicated treatment centers for Heart Arrhythmia so hopefully better mapping technology will follow. Wishing you the best in your on going treatment.

Thank you. It sure is a slog. I’ve not tried diltiazem for my svt yet. It didn’t do much for my a fib compare to metoprolol. I’m a fan of the leg pop up in the air when releasing the valsalva. I’ve never had luck with carotid massage. There is a theoretical stoke risk if there is a lot of calcified plaque. I bet your job was interesting, so many advances in cardiology.