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 240 and 340/min, with a regular ventricular response and a saw tooth pattern on EKG.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Atrial flutter can be a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

Management

Diagnostic Approach

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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ 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
Holter monitoring
❑ Exercise testing
❑ Order blood tests (if Atrial flutter has not been investigated before)

Thyroid function
Renal function
Hepatic function
 


Therapeutic Approach

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

 
 
 
 
 
 
Atrial flutter
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unstable
 
 
 
 
 
Stable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Look for the presence of any of these:
❑ Chronic heart failure
❑ Hypotension
❑ Acute myocardial infarction
 
 
 
 
 
❑ Administer anticoagulation therapy based on the risk of stroke, if total duration of flutter > 48 hours
❑ Administer rate control therapy (AV nodal blockers)

THEN

❑ Attempt conversion
❑ DC cardioversion
❑ Atrial pacing
❑ Pharmacological cardioversion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Assess need for therapy to prevent recurrence
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Administer antiarrythmic therapy to prevent recurrences
❑ Consider catheter ablation if antiarrhythmic therapy fails
 
 
 
 
 
 
 
 
 
 

Acute management of atrial flutter

Acute management of atrial flutter
Proposed therapy Recommendation
stable flutter
Conversion Atrial or transesophageal pacing
or
DC cardioversion
or
Ibutilide
or
Flecainide
or
Propafenone
or
Sotalol
or
Procainamide
or
Amiodarone
Rate control Beta blockers
or
Verapamil or diltiazem
or
Digitalis
or
Amiodarone


Acute management of atrial flutter
Proposed therapy Recommendation
Unstable atrial flutter
Conversion DC cardioversion
Rate control Beta blockers
or
Verapamil or diltiazem
or
Digitalis
or
Amiodarone


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. "ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary". Retrieved 15 August 2013.

References


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