Recognizing atrial flutter in the emergency department: Challenges in diagnosis

Area of Science:

• Cardiology
• Emergency Medicine
• Electrocardiography

Background:

• Atrial fibrillation (AF) and atrial flutter (AFL) require distinct management strategies beyond anticoagulation.
• Misclassification between AF and AFL is common and can lead to suboptimal patient care.
• Computerized ECG interpretation may contribute to diagnostic errors.

Purpose of the Study:

• To evaluate the diagnostic accuracy of AFL in an emergency department (ED) setting, excluding the influence of computerized interpretation.
• To identify predictors of misdiagnosis between AFL and AF.

Main Methods:

• Retrospective review of 2003 ECGs from patients discharged with AF or AFL.
• Independent reinterpretation of ECGs by two cardiologists, with an electrophysiologist serving as an arbitrator.
• Analysis of patient demographics and ECG characteristics to identify misdiagnosis predictors.

Main Results:

• Only 55.6% of AFL cases were correctly identified; 44.4% were misdiagnosed as AF.
• Patients misdiagnosed with AFL were older, more likely to have a prior AF diagnosis, and exhibited variable atrioventricular (AV) conduction.
• Variable AV conduction was an independent predictor of misdiagnosis (OR 2.47, 95% CI: 1.46-4.17).

Conclusions:

• Atrial flutter is frequently misdiagnosed as atrial fibrillation in the ED, even without computerized interpretation.
• Variable AV conduction is a critical, independent predictor of AFL misdiagnosis.
• Targeted physician education focusing on irregular ventricular response is essential for improving diagnostic accuracy and patient care.