ECG Report - Srinivas, 50 years | 12/07/26, 12:30 PM

Measurements

Primary Diagnosis: Atrial Flutter with 2:1 AV Block

• Sawtooth baseline (flutter waves, "F-waves") most prominent in leads II, III, aVF and V1 - the hallmark of atrial flutter
• No distinct P-waves - the flutter waves are continuous, without an isoelectric baseline between them
• Regular, rapid ventricular response at ~146 bpm

Additional Findings

1. Right Axis Deviation (QRS axis +105°)

• Deep S-wave in lead I, positive QRS in aVF
• Can indicate right ventricular strain, right bundle branch pattern, or lateral wall changes

2. Prolonged QTc - 508 ms (Critical)

• Normal QTc is <440 ms in men
• A QTc >500 ms carries elevated risk of Torsades de Pointes (a dangerous ventricular arrhythmia)
• This needs urgent attention - check electrolytes (K⁺, Mg²⁺, Ca²⁺) and review all QT-prolonging medications

3. Probable Lateral Infarct - Old

• Machine flags Q waves ≥35 ms and abnormal ST-T changes in V5-V6, I, and aVL
• This suggests a prior lateral MI (not acute)
• ST-segment depression and T-wave inversion in lateral leads can also be secondary to the rapid rate ("rate-related strain"), so clinical correlation with history and prior ECGs is essential

4. Ventricular Premature Complex (VPC)

• One or more beats with a short R-R interval were flagged

Clinical Significance & Suggested Actions

1. Rate control - With a ventricular rate of 146 bpm, the patient is likely symptomatic (palpitations, dyspnea, chest discomfort). Rate control with beta-blockers or calcium channel blockers (diltiazem/verapamil) should be considered.
2. Rhythm control / cardioversion - Depending on duration of flutter and anticoagulation status, electrical or pharmacological cardioversion may be appropriate.
3. Anticoagulation assessment - Atrial flutter carries thromboembolic risk similar to atrial fibrillation; CHA₂DS₂-VASc score should be calculated.
4. Electrolyte panel urgently - QTc of 508 ms is a medical concern. Check and correct K⁺, Mg²⁺; avoid or stop any QT-prolonging drugs.
5. Cardiology review - The combination of rapid flutter, prolonged QTc, and possible old lateral MI warrants cardiology evaluation.
6. Compare with prior ECGs - To determine whether the lateral infarct pattern and axis deviation are new or chronic.

Disclaimer: This is an AI-assisted interpretation for educational/informational purposes. All findings must be confirmed and acted upon by a qualified physician with access to the full clinical context.

The Bix Rule

When the ventricular rate in a regular tachycardia is between 150-160 bpm, always suspect a 2:1 atrial tachyarrhythmia - and look carefully for hidden P-waves or flutter waves buried within the QRS complex or T-wave.

Why It Applies Here

• Sinus tachycardia
• SVT
• Junctional tachycardia

The Trap in This ECG

• Ventricular rate = 146 bpm (falls right in the 150 bpm zone)
• The flutter rate = 333 bpm → 333 / 2 = ~166 bpm conducted rate
• Every 2nd flutter wave is hidden - buried in the QRS or T-wave
• Only when you look carefully at leads II, III, aVF and V1 do you see the sawtooth pattern

How to Unmask Hidden Flutter Waves (Practical Tips)

Key Teaching Point

• Rate ~150 bpm + regular rhythm = assume 2:1 atrial flutter until proven otherwise
• Always "march out" the baseline at twice the ventricular rate to look for buried flutter waves
• Missing it means missing the correct diagnosis and potentially giving wrong treatment