Atrial Flutter (mis)interpreted as Sinus Rhythm

A 70 pt h/o HTN, dyslipidemia, cardiac arrhythmia, CHF, PVD, DM

c/o L leg pain. What is the rhythm?

a. Sinus Rhythm

b. Atrial Flutter

c. Atrial fibrillation

d. Accelerated Idioventricular Rhythm

Figure 1

A 2:1 is not Mobitz II

Vignette: A 70 yo is admitted due to dizziness. What is your ECG interpretation?

Figure 1 - ECG case

The rhythm is sinus with an atrial rate of about 65 bpm and the ventricular rate of about 34 bpm. The PRI is 0.28 s and the QRS is 0.12 sec. There are 2 P wave for every 1 QRS (Figure 2).

Figure 2 - P waves marked with red arrows

Sinus rhythm with long PRI mimicking junctional rhythm

Vignette: Elderly patient with history of chronic smoking, DM, HTN and dyslipidemia was brought in due to  weakness and fall. Patient is being worked-up for possible CVA.

What is the rhythm?

Image 1

This is a regular, wide QRS complex rhythm with left anterior fascicular block (LAFB) and right bundle branch block (RBBB). Our differential are: junctional rhythm or a SR with a long PR interval with P hidden from view as it merges with the T wave. 

Image 2

The rhythm strip revealed the P waves and the long PR interval.

Going back to the 12 lead, if you look closely in lead II you see distortions at the descending portion of the T waves.

For the case, it was found that it was indeed stroke. Managed as that and later sent for rehab and risk factors addressed.

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