A 59-year-old man is in the emergency department with palpitation and mild dyspnea. He had experienced 3 similar episodes during the previous 4 months, that had subsided spontaneously in 1/2 – 1 hour. He had no chest pain. When free of palpitation, his exercise tolerance was good:

• Atrial flutter with 2:1 AV conduction
• Ventricular rate 139/min
• Possibility of inferior infarction cannot be ruled out

The computer ECG  interpretation program had diagnosed “acute inferior infarction”.

The patient remains free of chest pain. His cardiac enzymes are normal. He receives metoprolol. This ECG is recorded 30 minutes after ECG 1:

• Atrial flutter with variable AV conduction
• Ventricular rate 113/min

The “pseudo-q waves” in the inferior leads were actually the negative component of the flutter waves.
The patient underwent further investigation that showed no evidence of structural heart disease.

The patient undergoes DC cardioversion:

• Sinus rhythm, 82/min
• Normal ECG

Comment: Atrial flutter may occur in subjects who have no evidence of structural heart disease. The negative component of the flutter wave may mimic  the q wave of inferior infarction. The patient was started on propafenone and diltiazem. The possibility of ablation therapy (if the arrhythmia continued to recur) was discussed with him. He will be followed in the arrhythmia clinic.