Ventricular Flutter

Clinical Significance of Ventricular flutter

Extreme form of ventricular tachycardia (VT) with loss of organised electrical activity

• Associated with rapid and profound hemodynamic compromise
• Usually short lived due to progression to ventricular fibrillation
• As with ventricular fibrillation rapid initiation of advanced life support is required

How to Recognise Ventricular Flutter

• Continuous Sine Wave
• No identifiable P waves, QRS complexes, or T waves
• Rate usually > 200 beats / min

Clinical Pearl

The ECG looks identical when viewed upside down!

ECG Examples

Example 1

Typical appearance of ventricular flutter:

• Monomorphic sine wave at >200bpm.
• ECG looks identical when turned upside down.

Example 2

12-lead ECG example of ventricular flutter:

• Extremely rapid monomorphic sine wave at around 300 bpm.

Example 3

Ventricular flutter following a bolus of intravenous verapamil

• A supraventricular tachycardia converts to ventricular flutter after administration of verapamil. The rhythm subsequently degenerates into ventricular fibrillation.
• The rapid deterioration with verapamil suggests that the patient may have underlying Wolff-Parkinson White syndrome.
• In WPW, administration of verapamil or diltiazem during a supraventricular tachycardia may produce a paradoxical increase in ventricular rate by increasing conduction through the accessory pathway. With rapid atrial rhythms such as AF or flutter, the sudden onset of 1:1 AV conduction may produce ventricular rates of >300 beats per minute (i.e. ventricular flutter), which rapidly deteriorates to VF.

Related Topics

• Ventricular Fibrillation
• Ventricular Tachycardia

Advanced Reading

Online

• Wiesbauer F, Kühn P. ECG Yellow Belt online course: Become an ECG expert. Medmastery
• Wiesbauer F, Kühn P. ECG Blue Belt online course: Learn to diagnose any rhythm problem. Medmastery
• Rawshani A. Clinical ECG Interpretation ECG Waves
• Smith SW. Dr Smith’s ECG blog.

Textbooks

• Mattu A, Tabas JA, Brady WJ. Electrocardiography in Emergency, Acute, and Critical Care. 2e, 2019
• Brady WJ, Lipinski MJ et al. Electrocardiogram in Clinical Medicine. 1e, 2020
• Straus DG, Schocken DD. Marriott’s Practical Electrocardiography 13e, 2021
• Hampton J. The ECG Made Practical 7e, 2019
• Grauer K. ECG Pocket Brain (Expanded) 6e, 2014
• Brady WJ, Truwit JD. Critical Decisions in Emergency and Acute Care Electrocardiography 1e, 2009
• Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric 6e, 2008
• Mattu A, Brady W. ECG’s for the Emergency Physician Part I 1e, 2003 and Part II
• Chan TC. ECG in Emergency Medicine and Acute Care 1e, 2004

LITFL Further Reading

• ECG Library Basics – Waves, Intervals, Segments and Clinical Interpretation
• ECG A to Z by diagnosis – ECG interpretation in clinical context
• ECG Exigency and Cardiovascular Curveball – ECG Clinical Cases
• 100 ECG Quiz – Self-assessment tool for examination practice
• ECG Reference SITES and BOOKS – the best of the rest