AF associated tachycardia

Hi all,

There's recently been a lot of talk on here about AF alternating with/precipitating a different atrial tachycardia.

As I've mentioned here previously, I myself have experienced this to differing degrees ever since commencing daily Flecainide in March 2008 (100mg BID).

Attached hereto is a 12 lead ECG of one such episode I experienced in 2009. The timeline on this occasion was runs of ectopics/palpitations late evening in supermarket car-park followed by this rhythm that the ECG machine at the local NHS hospital (in Oban, Scotland) decided was 'accelerated junctional rhythm'. The 80 or so BPM tachycardia lasted around half an hour before suddenly converting to NSR at my normal resting HR of 60 or so. My last two AF episodes have included periods of this tachycardia. I can alternate between the two before converting to NSR from either one or the other. I always convert from either to around 60 BPM which is my usual resting HR.

No EP I've seen so far - including Sabine Ernst - knows quite what to make of it. No-one thinks it's atrial flutter. Sabine set it looked a bit like AF in between the very regularly spaced QRS complexes (particularly between leads V1 and V4)..

What do you guys make of it?? As for me, it looks a lot like NSR I'll admit but it certainly doesn't feel or behave rate-wise like it.

[drive.google.com]



Edited 5 time(s). Last edit at 04/26/2018 03:38PM by mwcf.

You'll need to set permissions on that file to make it publicly visible. I can't access it.

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Carey
You'll need to set permissions on that file to make it publicly visible. I can't access it.

I think I've changed the settings as required - please have another try Carey and let me know how you get on.

I see a what would be a normal ECG, just missing P-waves. I guess that's why they say "Accelerated Junctional Rhythm". I'm taking that to mean AV node depolarization at a rate near 80 bpm, which is about double what it would normally be.

That's definitely a puzzler.

A bit of advice - if you can edit the picture, you might want to blank out any personal info, like your name, date and location. I doubt you can apply for a passport or open a line of credit with an ECG, but the Internet is a wild place!

Yep, accelerated junctional rhythm. I see what he's saying about afib being visible in V1, but why it wouldn't be apparent in other leads is a mystery.

By any chance are you taking digoxin or were you at the time?

wolfpack,I think I've managed to do as you suggested, so thanks for that. It is indeed a bit of a puzzler. It's the apparent lack of P waves that's the kicker. But then again, my P waves a quite subdued even on a ECG of NSR - but that said they're still discernably there.

Carey, no; no digoxin ever - as a 99% vagal AFr I wouldn't touch the stuff.

The rhythm in question doesn't feel unpleasant; just not right. We truly are all unique experiments of one! In one way I'm glad it's not flutter..... but only providing it isn't something worse! But then again no EP I've ever seen seemed particularly concerned about it - including most recently Sabine Ernst. My own layman's take is that it might be the AV node 'thinking' "I'm not having this" as in the AF trying to get through, so it initiates a regular rhythm of its own. I really don't know what else to think. My NSR ECG always comes up as First Degree AV Block, but 100mg BID Flecainide in and of itself is enough to add circa 40ms on to a normal (<200ms) PR interval.



Edited 1 time(s). Last edit at 04/26/2018 04:57PM by mwcf.

Hi Mike - Just FYI... When I first began to experience flutter, it wasn't a dramatic change but a very subtle difference that I didn't fully recognize at first but as I had read others describing, I began to note short, minor episodes that were definitely not normal but not typically what I knew to be my traditional Afib... and over time, those did turn into a fully recognizable a-flutter pattern. It wasn't always just flutter. I'd still have one or the other and then more commonly... afib escallating to flutter.
What drove my second ablation, was going into flutter full tilt which was nasty. Don't wish that on anyone.

Jackie

For what it’s worth, I don’t think that rhythm is anywhere near dangerous. With a regular ventricular rate of 80 you will be hemodynamically stable. The risk, I’d guess, is the same as AF, and that would be clots forming in the atria. Sensible anticoagulation would mitigate that.

Jackie,

Noted, but the arrhythmia I'm talking about has been happening on occasion your over 10 years now and hasn't evolved/progressed into anything like AFlutter. That said it has always occurred after AF - it was only the first time I had it (as per the ECG I attached) where it pretty much started up before AF, but I wouldn't want even to swear to that as the runs of ectopics I had before it for 20 or 30 secs could easily have been a short burst of AF anyway. More recently it's always been after AF has started with it almost always starting when I stand up and start walking around with AF and then reverting back to AF a few minutes after I lie down again - definitely a postural component so likely - along with all of my AF history - vagally/ANS influenced.

wolfpack,

With CHADS zero and episodes never longer than a few hours (usually 1 or 2 hrs) no EP I've ever seen (and I've seen a few over the years) has ever wanted me on an AC.
That said, it's hardly all an exact science is it! I've mostly read no AC needed (CHADS 0) where episodes no longer than 24 hrs but then again I've read that AC should be used after episodes of any longer than a few minutes. As always, lots of opinions out there, but one just has to take a sensible consensus view and keep one's fingers crossed. After all, one way or another none of us are getting out of here alive!

Cheers,

Mike

It's possible you are capturing some sort of meta-stable state between NSR and AF. I know in my case, as I've seen many times on Kardia, that immediately after converting I will see regularly spaced QRS complexes at a higher than normal rate and still a somewhat "noisy" baseline with barely recognizable P-waves. I attribute this to the atria "waking back up" after having the cardiac equivalent of an epileptic seizure.

Interesting idea wolfpack.

It certainly sounds plausible/possible, but for me the non-AF 80-90BPM arrhythmia doesn't feel like NSR as it feels more unnatural and kind of 'bounding'. But I do take your point re my ECG - that certainly looks pretty much like NSR except for the lack of (or barely discernible) P waves.

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mwcf
that certainly looks pretty much like NSR except for the lack of (or barely discernible) P waves.

They're discernible but they're inverted. That's what makes it a junctional rhythm. If not for that then yeah, it would be NSR.

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wolfpack
I know in my case, as I've seen many times on Kardia, that immediately after converting I will see regularly spaced QRS complexes at a higher than normal rate and still a somewhat "noisy" baseline with barely recognizable P-waves.

Wolf, do any of the patterns on the linked Kardia ECG's look like what you are talking about? See here: <[www.afibbers.org] Obviously pages 1 & 3 are afib.

George

George,

What do I know, but 4 to 8 certainly look like things are progressively calming down with 8 clearly and most distinctly being NSR nice and tidy. 5 through 7 look a bit more chaotic within their otherwise orderliness if you know what I mean - as in QRSs more strung out and P waves larger and closer after the QRSs. Porbably telling you nothing you don't already know but whatever!

What did you make of my ECG strip? I don't suppose there's much to add to what wolf and Carey have already said, but your meticulous engineer's take would still nonetheless be appreciated!

For the record, we're not doctors and we don't play them on the Internet!

Now that's out of the way, yes, George, mine do look similar to yours post-conversion although the rates are lower (I was about 73 bpm after converting). That was with 12.5 mg metoprolol and 150mg propafenone, so there was definitely some beta blockade going on from both drugs.

If I can figure out google drive I'll post them.

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wolfpack
If I can figure out google drive I'll post them.

Much easier: http://postimage.org

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wolfpack
For the record, we're not doctors and we don't play them on the Internet!

Yep, I'm an engineer, too. Just looking for more data...

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wolfpack
Now that's out of the way, yes, George, mine do look similar to yours post-conversion although the rates are lower (I was about 73 bpm after converting). That was with 12.5 mg metoprolol and 150mg propafenone, so there was definitely some beta blockade going on from both drugs.

If I can figure out google drive I'll post them.

The BB and propafenone, which also has BB in it, will certainly slow your rate.

FYI, if you logged into drive.google.com, you upload the file then right click and get a sharable link and make sure the permissions are set to "anybody can view."

Thanks for the comments!

Here goes...

1. Monday’s episode [s14.postimg.cc]
2. Monday’s episode shortly after conversion [s14.postimg.cc]
3. Monday’s episode long after conversion [s14.postimg.cc]

and...

4. Just for grins, AF on the morning of my ablation 2.5 years ago. I was off meds for 2 days at this point. [s14.postimg.cc]

Thanks Wolf!

Don't know how you hold the Kardia, but I hold one side in my right hand and put the other on my right thigh or just below the hip. That is more of a Lead II presentation and causes the p wave to stand out a bit more.

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mwcf
George,

What do I know, but 4 to 8 certainly look like things are progressively calming down with 8 clearly and most distinctly being NSR nice and tidy. 5 through 7 look a bit more chaotic within their otherwise orderliness if you know what I mean - as in QRSs more strung out and P waves larger and closer after the QRSs. Porbably telling you nothing you don't already know but whatever!

What did you make of my ECG strip? I don't suppose there's much to add to what wolf and Carey have already said, but your meticulous engineer's take would still nonetheless be appreciated!

BTW, 8 was pure NSR a day later, no flec in the system. I concur with the progressively calming down. The interesting thing is that I started the breathing device to increase CO2 before 4 and shortly thereafter went from afib to regularly spaced QRS. Then I continued and the rate slowed down as illustrated with 5. Don't remember as it was in the wee hours if I continued for 6, but then went to sleep between 6 & 7. I've thought about trying the breathing device without flec the next time and see what happens. Would be interesting.

If people like Sabine Ernst are having a hard time with it, I don't know enough to even offer an opinion ....

Cheers,

George

Right hand, left hand. Roughly a Lead I presentation.

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wolfpack
Right hand, left hand. Roughly a Lead I presentation.

Yep, I used to do that & found right hand and something lower down on left gave a much more distinct p wave.