Download Correspondence: Atrial Flutter with 1:1 response

slow the ventricular response, this diagnosis cannot be safely made. The ventricular rate in this instance is approximately 238 and in the absence of
demonstrated flutter waves the diagnosis would
have to be simply supraventricular tachycardia. In
fact, I would suggest that the most likely diagnosis
is AV junctional tachycardia. It should be noted
that the associated ST segment depression present
at this rate is nondiagnostic by itself.
John C. Dormois, M.D.
Medical Director
Western Reserve Life
Assurance of Ohio
Correspondence
Atrial Flutter with 1:1 Response
To the Editor I would like to comment on the series
of electrocardiograms presented in the OctoberDecember issue of the Journal of Life Insurance
Medicine.
The above letter was referred to the author of the
article in question, who offered the following reply:
The case presented by Dr. Ferrer was that of a 48year-old man who had a history of some type of
chest discomfort and palpitations. He was eventually admitted to the hospital at which time his
admission electrocardiogram was totally normal.
The second electrocardiogram was then done
which showed a supraventricular tachycardia. In
the discussion of this electrocardiogram, Dr.
Ferrer indicated that this represented an example
of atrial flutter with 1:1 conduction. This is a possible interpretation, although I believe that the data
present is insufficient to make that diagnosis.
To the Editor: I enjoyed reading the comments of
Dr. Dormois concerning the tracing showing atrial
flutter with a 1:1 AV response. Once one goes
through the preliminary analysis for supraventricular tachycardias, as reviewed by Dr. Dormois,
one makes a decision based on the rate in this arrhythmia. The rates of atrial flutter, atrial tachycardia and junctional tachycardia are defined in the
international reference text "Nomenclature and
Criteria for Diagnosis of Diseases of the Heart and
Great Vessels" published and prepared by the
Criteria Committee of the New York Heart Association. (The editor-in-chief and chairman of this committee for the 8th Edition was Dr. M. Irene Ferrer.)
After widespread review of the subject by the
criteria committee, the criteria for rates for these
rhythms were found to be as follows: Atrial flutteratrial rates between 200 and 400 per minute; Atrial
tachycardia-atrial rates 140-200 per minute; Junctional tachycardia — 100-200 per minute. Thus,
atrial rates over 200 per minute are almost always
due to atrial flutter. The last 4 patients I have seen
with atrial flutter have had atrial rates between 238
and 240 per minute.
When the QRS complex is narrow, an arrhythmia
of supraventricular origin is by definition present.
In order to further categorize the arrhythmia, a
careful search must be made for the P wave. When
the P wave is present, its relationship to the QRS
complex and its morphology helps to accurately
characterize the origin of the ectopic rhythm.
When a P wave is not readily identifiable on the
electrocardiogram, it indicates that the P wave is
either buried within the QRS complex or T wave or
the arrhythmia originates in the AV node or below
and there is no associated retrograde conduction.
In this situation, the rate of the ventricular response
does help make a preliminary estimate of where
the origin of the arrhythmia may lie. In contradistinction to what was outlined in the Journal,
most authorities on the subject of supraventricular
tachycardia indicate that so-called atrial tachycardia has an atrial rate somewhere between 160 and
250 beats per minute whereas the atrial rate in
atrial flutter is commonly between 250 and 350
beats per minute. Rarely is the atrial rate slower
than that. When drug therapy is present, the atrial
rate might well be slower, however.
The importance of the rapid diagnosis of 1:1 Atrial
flutter cannot be overemphasized as it is usually
(as in this man) a serious cardiac emergency.
M. Irene Ferrer, M.D.
Cardiologist, Metropolitan Life Insurance Company
Professor of Clinical Medicine
College of Physicians and Surgeons
Columbia University
Director, Electrocardiographic Laboratory
Columbia-Presbyterian Medical Center
New York, N.Y.
Although the electrocardiogram demonstrated on
page 19 could in fact be atrial flutter, without
demonstrating the characteristic saw-tooth appearance of the flutter wave by some maneuver to
27