In nursing school, you will learn different types of heart dysrhythmias and will be required to identify rhythms on exams. In this article, I want to explain the difference between a-fib and a-flutter.

Many times when students are learning EKG rhythms, they get confused on atrial fibrillation and atrial flutter. In addition, they sometimes get those rhythms confused with normal sinus rhythm. However, I have identified a few steps you can take to help you avoid getting these heart rhythms confused. After you read this article and watch the video tutorial, don’t forget to take the EKG quiz to test how well you grasp this material.

Before you start reading this article, you may want to refresh your memory on the PQRST wave of the EKG, because in order to understand this material you must be familiar with what p-waves and r-waves are. Here is a video tutorial on how to learn the PQRST wave.

Video Tutorial on EKG Rhythms

5 Easy Steps to Always Follow When Analyzing Rhythms

When analyzing any type of heart rhythm I recommend following the 5 steps below. If you answer each of these questions and apply it to the “hallmarks” of all the rhythms, you should not have any problem identifying rhythms. This is because every dysrhythmia has a certain “hallmark” that sets it apart from the other rhythms.

1. Are p-waves present? If so, how many p-waves are present in 6 seconds? (when you count the p-waves you are calculating the atrial rate) Normal atrial rates are 60-100 beats per minute.
2. Are the p-waves regular? This is where you will measure the distance between each p-wave with calipers or a sheet of paper.
3. Are the r-waves regular? Again, you will use calipers or a sheet of paper to measure the distance between each r-wave to see if they are regular.
4. How many r-waves are present in 6 seconds? This is how to calculate the ventricular rate. You do this the same way you measured the atrial rate. A normal ventricular rate of 60-100 bpm.
5. If there are p-waves, what is the measurement of the PR-interval? What is the width of the QRS complex? Note: You cannot measure a PR interval with a-fib or a-flutter because there are no p-waves present.

Difference Between Atrial Fibrillation and Atrial Flutter

Now, let’s talk about the difference between the two rhythms. But first, let’s look at a normal rhythm.

In Normal Sinus Rhythm (NSR), you will always have the following:

1. P-waves will be present with atrial rate of 60-100 bpms (meaning there will be 6-10 p-waves present in 6 seconds)
2. P-waves will be regular
3. R-waves will be regular
4. There will be 6-10 QRS complexes in 6 seconds to equal a ventricular rate of 60-100 bpms
5. PR interval will be measurable and be a length of 0.12-0.20 seconds. And QRS complex will measure less than 0.12 seconds.

In atrial fibrillation, you will always have the following:

1. No p-waves will be present. The little humps you are seeing are called f-waves (fibrillary waves). Therefore, you cannot count the atrial rate.
2. P-waves are not present so you can’t measure if the p-waves are regular.
3. R-waves will be irregular because of the random fibrillary waves quivering at various times.
4. Typically there are 6-10 r-waves in a-fib in 6 seconds, BUT if the patient is having what is called a-fib with RVR (rapid ventricular response) you can have many r-waves varying from 11-200. On the heart monitor you would see a fluctuating heart rate of 110-200 when the a-fib is not controlled.
5. PR interval is not measurable because you don’t have p-waves and the QRS complex is usually less than 0.12 seconds.

In atrial flutter, you will always have the following:

1. No p-waves will be present BUT a wave of f-wave called SAW-TOOTH WAVES. This will NEVER be present in a-fib. This is a big difference in how you tell if the rhythm is a-flutter or a-fib.
2. P-waves are not present so you can’t measure if the p-waves are regular.
3. R-waves tend to be regular BUT the can be irregular depending on the quivering of the atrium. You can see in the example I provided that this r-waves are irregular.
4. Typically there are 6-10 r-waves in a-flutter in 6 seconds, BUT if the patient is having what is called rapid a-flutter, you can have many r-waves varying from 11-200. On the heart monitor you would see a fluctuating heart rate of 110-200 when the a-flutter is not controlled.
5. PR interval is not measurable because you don’t have p-waves and the QRS complex is usually less than 0.12 seconds.

Conclusion

The major difference between a-fib and a-flutter are the saw-tooth waves in a-flutter and that in a-fib the r-waves are always irregular. The r-waves in a-flutter can be regular or irregular.

Now test your knowledge and take the EKG practice test.