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Atrial flutter produces organized atrial activity at 250–350 bpm, appearing as sawtooth flutter waves (especially in II, III, aVF). With 2:1 conduction, every second flutter wave is conducted, resulting in a ventricular rate ~150 bpm. Sinus tachycardia shows upright P waves, not flutter waves. Atrial fibrillation is irregularly irregular without organized flutter waves. Ventricular tachycardia is wide-complex. Recognition of atrial flutter patterns is vital because treatment often differs from that of atrial fibrillation.

Stress testing evaluates the heart’s response to exercise or pharmacologic stress by monitoring ECG, BP, and symptoms. It helps detect ischemia, arrhythmias, or exercise intolerance. It does not measure lung capacity, cholesterol, or cardiac structure (echo). It complements, not replaces, other diagnostic modalities.

The Bruce protocol is the most common adult treadmill stress protocol, with progressive 3-minute stages increasing in speed and incline. Balke and Naughton are gentler alternatives for elderly or deconditioned patients. Ramp provides gradual continuous increases. Familiarity with protocols ensures appropriate test selection.

The presence of fusion and capture beats is diagnostic for ventricular tachycardia (VT). VT shows wide QRS complexes, rapid ventricular rate, and absence of consistent P-QRS relationships. SVT with aberrancy may mimic VT but lacks fusion/capture beats. Atrial flutter has sawtooth waves and is typically narrower unless aberrancy is present. MAT shows multiple P-wave morphologies with narrow QRS complexes. Correct identification of VT is critical for patient safety, as it may require immediate intervention.

Junctional escape rhythm arises from the AV junction when the SA node fails. It has a rate of 40–60 bpm, narrow QRS complexes, and absent or inverted P waves. Sinus bradycardia has upright P waves. Idioventricular rhythm is slower (20–40 bpm) with wide QRS. Third-degree block shows AV dissociation. Correct identification guides management.