Regular alternate irregular heartbeats, .75 sec then 1 sec continuous- is this AF or some variation?

[Speed]

Noticed this morning when getting ready for a group bike ride, that I had an arrhythmia - I was slightly breathless as I rushed around getting my kit together. As always, a quick check of the pulse shows my pulse is fast and irregular. Whip out the 1 lead Kardia and first off it says possible AF @ HR of 97 - pretty typical for me. I retake 5 mins later after resting to see it changed / resolved and it comes up twice with unclassified HR of 99. Now normally my AF starts at around 110bpm and if I rest and take Flecainide, drops down to around 80 bpm before later returning to NSR. If I’m over 100, the Kardia returns”Tachicardia”but when it later drops to the 80’s it shows “possible AF”. My EP says that the Tachycardia is almost certainly faster AF and not a transient state, though the Kardia traces do show it as very regular when over 100.

Initially I thought that maybe 99 was on the cusp of AF / Tachy and so it didn’t want to commit 🤔. But when I looked closely at the trace, I could see that it was ABSOLUTELY over the 30 sec recording, showing alternate beats of .75 secs and 1 sec gaps. Additionally, as I could not see a P wave (though this is hard for me to be absolutely sure about) and I believe this is prerequisite for a “normal” (none AF) beat, it suggests these aren’t an eptopic followed by a normal beat.

I have seen some reference previously on here to arrhythmia that follow a similar regular pattern though that seemed to be 2 or 3 ectopics followed by a single normal beat.

Does anyone recognise this pattern, know the name of it (so I can consult Dr Google) or able to give any information / personal experience if they have experienced similar?

Would be nice to know if this is a progression and something I should follow up or just a passing phase. I will be sending a copy of the trace to my Arrhythmia nurse for her thoughts.

[mjames1]

Kardia will only show "tachycardia" if your HR is over 100. If you are in afib, Kardia will say "afib" and not "tachycardia", regardless of your heart rate. "Unclassified" could be any number of things, including multiple ectopics. Hopefully this helps some.

Jim

[Speed in reply to mjames1]

Hi Jim. Thanks for that, however, if that is the case, then presumably during a typical episode, when my HR will initially be > 100 and Kardia will say Tachycardia and then, after a few hours, drop to < 100 and say possible AF, I’m experiencing 2 separate arrhythmia, one directly flowing the other and happening every time I have an episode and always in the same sequence. It’s happened for so long now that it is absolutely not a coincidence and so is a thing. Has anyone else experienced this?

Incidentally, my EP’s view, (who is familiar with and rates the Kardia, - he was the one who originally, 3 yrs ago, advised me to get one) believes that the tachycardia is actually AF but when it’s faster, it appears more regular and so the Kardia does not tag it as AF.

[mjames1 in reply to Speed]

Not unusual to have more than one type of arrhythmia during an episode. My flutter or possibly atach frequently morph's into afib. It really comes down to reading the ekg by a trained ep. So if your ep thinks the "tachycardia" readings are afib, then go with that, however I didn't get the impression he'd bet the farm on it

I've shown identical ekg's to several ep's in top 10 teaching hospitals and guess what. Not all of them read them the same with afib, atach, SVT and flutter being interchanged. I think the only way they know for sure is when they get you on the table for an ep study and even then.

Jim

[Peony4575 in reply to Speed]

My AF episodes have been 170 bpm Kardia 1 says AF. I do have bits and pieces of tachycardia not that fast but over 100. The sensation in my chest is totally different . Heart doesn’t bounce around when it’s tachycardia and Kardia says Tachycardia

[Autumn_Leaves]

Ectopics don’t have a P wave either. Several ectopics on a 30 second Kardia trace can sometimes return a verdict of Possible AF or Unclassified. Ectopics can occur as a pattern, such as bigemeny or trigemeny. You need an experienced eye to look at your Kardia trace.

[Speed in reply to Autumn_Leaves]

Thanks for that.

My original thought was a scenario could be that the 1 sec beat was a normal beat instigated by the Sinus node and so with a P wave with the .75 sec beat being an early ectopic beat and so no P wave. This would fit with my normal resting pulse being about 60 (1 sec apart), However, with there being no P waves at all does this suggest that all the beats are none Sinus node driven and so instead, some very regular alternating ectopics or alternatively, a strangely regular AF (so not really fibrillating) 🤔

[Ppiman]

That must have been a worrying occasion, and just before a pleasant bike ride, too. I think that AF is reported by Kardia only if there's a lack of P wave along with irregularity The atrial signal, if it's there, will be only just visible on the trace just before the large "R" spike. If there is a P wave, then the irregularity won't be AF but something like multiple ectopic beats (PAC or PVC), which I often get. Also, if you have any widening of the QRS segment, a heart timing issue, often caused perhaps by a bundle block, Kardia will only report on this with its "Advanced Determinations" enabled.

Steve

[Halfheart]

I have had long runs of that exact same thing, and it turned out to be Atrial Flutter with variable block. Indications for that are: fairly regular; p-waves not easy to see; intervals that correspond to 75bpm and/or 150bpm, possibly alternating between the two, giving an overall rate around 100bpm. The only way to be sure is to get a ecg where they can see the flutter waves on Lead III. You can't see them on a normal Kardia or Apple Watch. The Kardia 6L will show it (I managed to order one on Amazon and have it arrive before the episode stopped!). This is just one of many possibilities though.

[dmac4646]

do you have enhanced monitoring on the Kardia

[Speed in reply to dmac4646]

No, just standard none subscription.

[dmac4646 in reply to Speed]

the enhanced monitoring tells you if you have ectopics