Variable electrocardiographic characteristics of isthmus-dependent atrial flutter
Open accessAbstract
Objectives The purpose of this study was to characterize variations in flutter-wave (F-wave) morphology among patients with clockwise isthmus-dependent (CWID) and counterclockwise isthmus-dependent (CCWID) right atrial flutter (AFL) and to attempt to correlate F-wave morphology with echocardiographic data and clinical patient characteristics.Background Variations in F-wave morphology on surface electrocardiogram (ECG) during CCWID and CWID flutter have been reported but never systematically characterized.Methods Over a four-year period, 139 patients with AFL on ECG underwent electrophysiologic study and echocardiography at our institution. Electrocardiographic data, intracardiac recordings, echocardiographic data, and patient characteristics were reviewed retrospectively.Results Of 156 AFLs evaluated, 130 were CCWID, 26 were CWID. Three types of CCWID flutter were observed: type 1 had purely negative F-waves inferiorly, types 2 and 3 had F-waves inferiorly with small (type 2) or broad (type 3) positive terminal deflections; CCWID flutter types 2 and 3 were associated with higher incidence of left atrial (LA) enlargement, heart disease, and atrial fibrillation (Afib) than type 1. Two types of CWID flutter were observed: type 1 had notched positive F-waves with a distinct isoelectric segment inferiorly. Type 2 had broader F-waves inferiorly with positive and negative components and a short isoelectric segment.Conclusions Variable ECG patterns for CCWID and CWID AFL exist. A positive component of the F-wave in the inferior leads during CCWID flutter is associated with an increased likelihood of heart disease, Afib, and LA enlargement.
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An ECG pattern with regular, predominantly negative atrial deflections in inferior leads (saw-tooth) at rates 240-350/min indicates CTI-dependent AFL if there is no prior history of surgery or ablation.
“An ECG pattern with regular, predominantly negative atrial deflections in inferior leads ('saw-tooth pattern') at rates 240 -350/ min indicates CTI-dependent AFL if there is no prior history of surgery or ablation.121,176”
From European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE) (2017) · cites this paper as [176]
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- Authors
- Milliez, P., Richardson, A. W., Obioha-Ngwu, O., Zimetbaum, P. J., Papageorgiou, P., & Josephson, M. E.
- Affiliations
- Beth Israel Deaconess Medical Center (US)
- Corresponding author
- Josephson, Mark E
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2002-09
- Volume
- 40
- Issue
- 6
- Pages
- 1125-1132
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W1965762997
- Cited by
- 68
- References
- 22
- Citations by year
- 2025: 2 · 2024: 3 · 2023: 1 · 2022: 2 · 2021: 5 · 2020: 2 · 2019: 1 · 2018: 2 · 2017: 3 · 2016: 1 · 2015: 2 · 2014: 4 · 2013: 1 · 2012: 1
- FWCI
- 2.85
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Arrhythmias and Treatments
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Atrial Fibrillation Management and Outcomes
- Keywords
- isthmus-dependent atrial flutter, right atrial flutter, inferior leads, left atrial enlargement, atrial fibrillation, heart disease
- MeSH terms
- Adult, Aged, Aged, 80 and over, Atrial Flutter, Echocardiography, Electrocardiography, Female, Heart Atria, Humans, Male, Middle Aged, Retrospective Studies, Sensitivity and Specificity, Atrial Function, Right
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
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