"A wise man walks with his head bowed, humble like the dust." Master Kan (circa 1972)

A junior doctor is reviewing a 63 year old male smoker presenting to ER/ED. The patient had been a spectator at a rugby match that evening and had developed sudden onset of palpitations associated with shortness of breath. He has a significant history of ischemic heart disease. Apart from tachycardia, there is nothing to find on examination. The reviewing doctor has written some comments (shown below) in the admission note regarding the ECG at presentation.

Admission note: ' ECG, TWI (T wave inversion) and ST depression: leads I, aVL, V6, P waves present in V1. Probable sinus tachycardia in setting of anterolateral ischemia'.

What do you think?

The doctor is incorrect. This is not a sinus tachycardia and no ischemia-related ST changes are present on this ECG. This is a case of atrial flutter. The following article aims to improve your ability to diagnose this arrhythmia.

Why does Atrial Flutter fool us so often? Top 10 Tips to Minimise Uncertainty