Atrial flutter resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hilda Mahmoudi M.D., M.P.H.[2]; Priyamvada Singh, M.D. [3]

Definition

Atrial flutter is a reenterant arrhythmia with atrial rates between 250 and 340/min with regular ventricular response. EKG usually shows a saw tooth pattern.

Causes

Life Threatening Causes

Life-threatening causes include conditions which result in death or permanent disability within 24 hours if left untreated.

Common Causes

Management

Shown below is an algorithm summarizing the initial approach to atrial fibrillation.

 
Characterize the symptoms:
❑ Asymptomatic PalpitationsDyspnea
Fatigue Chest discomfort Lightheadedness
Syncope Exercise induced fatigue

Characterize the timing of the symptoms:
❑ Onset

❑ First episode
❑ Recurrent

❑ Duration
❑ Frequency
❑ Termination of the episode

❑ Spontaneous
❑ Medication use
❑ Not terminated
 
 
 
 
 
 
 
 
 
Identify possible triggers:
InfectionCaffeineAlcohol
Nicotine Recreational drugsHypovolemia
HyperthyroidismHypoxiaAcidosis
HypokalemiaHyperkalemiaHypoglycemia
❑ Treatment of AF❑ Acute MI❑ Digitalis toxicity
HypothermiaToxinsCardiac tamponade
Pulmonary embolismCoronary thrombosisTrauma
❑ Post cardiac surgery
 
 
 
 
 
 
 
 
 
 
❑ Examine the patient
❑ Order an ECG

♦ Atrial flutter rhythm

❑ Absent P waves
❑ Atrial rate 240-340 beats/minute
❑ Atrial rate:ventricular rate ratio 2:1 (most commonly)
❑ Saw tooth pattern in leads II, III, and aVF

♦ Other signs on ECG

Left ventricular hypertrophy
Preexcitation
Bundle branch block
❑ Previous myocardial infarction
❑ Other types of arrhythmias
 
 
 
 
 
 
 
 
 

❑ Order a transthoracic echocardiogram
❑ Order blood tests (if Atrial flutter has not been investigated before)

❑ Thyroid function
❑ Renal function
❑ Hepatic function
 


Shown below is an algorithm summarizing the approach to atrial flutter.[3]

 
 
 
 
 
 
Atrial flutter
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unstable
 
 
 
 
 
 
 
Stable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CHF, shock, acute MI
 
 
 
Rate control:
AV-nodal blockers
 
 
 
 
 
 
Conversion
DC cardioversion
Atrial pacing
Pharmacological conversion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DC cardioversion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If therapy for prevention of recurrences warranted
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antiarrhythmic drugs
 
 
 
 
 
 
 
 
 
 
 
Catheter ablation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Management of atrial flutter depending on hemodynamic stability.
Attempts to electively revert atrial flutter to sinus rhythm should be preceded and followed by anticoagulant precautions, as per AF.
AV indicates atrioventricular; DC, direct current.
Algorithm based on the 2003 ACC/AHA/ESC guidelines for the management of supraventricular arrhythmias.[3]

Do's

  • It is often the result of pulmonary disease exacerbation, pericarditis, and open heart surgery
  • Radiofrequency catheter ablation is superior to medical therapy.

Anticoagulation for atrial flutter

Don'ts

References

  1. Gutierrez SD, Earing MG, Singh AK, Tweddell JS, Bartz PJ (2012). "Atrial Tachyarrhythmias and the Cox-maze Procedure in Congenital Heart Disease". Congenit Heart Dis. doi:10.1111/chd.12031. PMID 23280242. Unknown parameter |month= ignored (help)
  2. Granada, J.; Uribe, W.; Chyou, PH.; Maassen, K.; Vierkant, R.; Smith, PN.; Hayes, J.; Eaker, E.; Vidaillet, H. (2000). "Incidence and predictors of atrial flutter in the general population". J Am Coll Cardiol. 36 (7): 2242–6. PMID 11127467. Unknown parameter |month= ignored (help)
  3. 3.0 3.1 "ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary". Retrieved 15 August 2013.

References


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