PubMed · 4851492
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M I Ferrer. 1974. Editorial: Atrial flutter.. https://doi.org/10.1378/chest.66.2.111
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In summary, the irregular dynamics of progression of 4:1 AV block in atrial flutter, presumably different from those observed in similar degrees of rate-dependent block, most likely reflected the complex electrophysiologic mechanisms operating during the highest degrees of AV nodal block. Occurrence of previously undescribed arrhythmias, namely Wenckebach periods during 4:1 and 6:1 block, tends to support the multilevel block hypothesis.
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