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Heart 1998;80:80-85 ( July )
a Department of
Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan
South Road, Taipei, 10018 Taiwan, b Department
of Internal Medicine, National Cheng-Kung University Hospital, Tainan,
Taiwan
Correspondence to: Dr Huang.
Accepted for publication 18 February 1997
Objective
To develop
new electrocardiographic (ECG) criteria for the differentiation between
counterclockwise and clockwise atrial flutters.
BackgroundTraditionally,
the ECG differentiation between counterclockwise and clockwise atrial
flutters is based on the flutter wave polarity in the inferior leads.
However, determination of flutter wave polarity is subjective and
sometimes difficult, especially in flutter waves of undulating pattern.
PatientsThe study
comprised 37 consecutive patients with drug resistant atrial flutter;
30 had counterclockwise and 17 had clockwise atrial flutter (10 had
both forms of atrial flutter). The isthmus dependence was confirmed by
entrainment study and catheter ablation. The ECG patterns of both types
of atrial flutter were compared and the flutter wave polarity in the
inferior leads was determined by four independent cardiologists.
ResultsThe flutter
wave polarity in the inferior leads appeared negative in 24, positive
in one, and equivocal in five of the counterclockwise atrial flutters;
polarity appeared negative in one, positive in 10, and equivocal in six
of the clockwise atrial flutters. However, the aVF/lead I flutter wave
amplitude ratio was > 2.5 in all counterclockwise but < 2.5 in all
clockwise atrial flutters. The flutter wave nadirs in the inferior
leads corresponded to the upstrokes in V1 in all counterclockwise
atrial flutters, but corresponded to the downstrokes in V1 in all
clockwise atrial flutters.
ConclusionsThe
flutter wave polarity in the inferior leads does not correlate well
with the flutter wave rotating direction. However, counterclockwise and
clockwise atrial flutters can be differentiated by new ECG criteria
with high accuracy.
This article has been cited by other articles:
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  R. Mantovan, M. A. Gatzoulis, A. Pedrocco, P. Ius, C. Cavallini, A. De Leo, R. Zecchel, V. Calzolari, C. Valfre, and P. Stritoni Supraventricular arrhythmia before and after surgical closure of atrial septal defects: spectrum, prognosis and management Europace, January 1, 2003; 5(2): 133 - 138. [Abstract] [PDF]
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 J. E. Marine, V. J. Korley, O. Obioha-Ngwu, J. Chen, P. Zimetbaum, P. Papageorgiou, P. Milliez, and M. E. Josephson Different Patterns of Interatrial Conduction in Clockwise and Counterclockwise Atrial Flutter Circulation, September 4, 2001; 104(10): 1153 - 1157. [Abstract] [Full Text] [PDF]
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 A Nabar, L M Rodriguez, C Timmermans, R van Mechelen, and H J J Wellens Class IC antiarrhythmic drug induced atrial flutter: electrocardiographic and electrophysiological findings and their importance for long term outcome after right atrial isthmus ablation Heart, April 1, 2001; 85(4): 424 - 429. [Abstract] [Full Text]
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