A 79 year-old man presents to the emergency room with increasing fatigue and shortness of breath over the past several weeks.  His ECG done in the ER is shown below:

• Atrial flutter with 4:1 conduction, Ventricular rate 84/min
• Low Voltage QRS

Comment: The flutter waves are denoted with the “P”.  The flutter waves are predominantly negative in the inferior leads, positive in V1 and negative in V6 which suggests this is likely “typical” or cavotricuspid isthmus dependent atrial flutter and easily amenable to catheter ablation.