Atrial flutter resident survival guide

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

• Acute coronary syndromes
• Cardiomyopathy
• Carbon monoxide poisoning
• Congenital heart disease
• Hypertensive heart disease
• Hyperthyroidism
• Mitral valve disease
• Pulmonary embolism
• Myocardial infarction

Management

Diagnostic Approach

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

		Characterize the symptoms: ❑ Asymptomatic ❑ Palpitations ❑ Dyspnea ❑ 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: ❑ Infection ❑ Caffeine ❑ Alcohol ❑ Nicotine ❑ Recreational drugs ❑ Hypovolemia ❑ Hyperthyroidism ❑ Hypoxia ❑ Acidosis ❑ Hypokalemia ❑ Hyperkalemia ❑ Hypoglycemia ❑ Treatment of AF ❑ Acute MI ❑ Digitalis toxicity ❑ Hypothermia ❑ Toxins ❑ Cardiac tamponade ❑ Post cardiac surgery ❑ Coronary thrombosis ❑ Trauma ❑ Pulmonary embolism
		❑ 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.

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

Long term management of atrial flutter

Long term management of atrial flutter Proposed therapy Recommendation ▸ First episode and well-tolerated atrial flutter ▸ Cardioversion alone or ▸ Catheter ablation ▸ Recurrent and well-tolerated atrial flutter ▸ Catheter ablation or ▸ Dofetilide or ▸ Amiodarone or Sotalol or Flecainide or Quinidine or Propafenone or Procainamide or Disopyramide ▸ Poorly tolerated atrial flutter ▸ Catheter ablation ▸ Atrial flutter appearing after use of class Ic agents or amiodarone for treatment of AF ▸ Catheter ablation or ▸ Stop current drug and use another ▸ Symptomatic non–CTI-dependent flutter after failed antiarrhythmic drug therapy Catheter ablation

Pharmacological cardioversion

Pharmacological Cardioversion for Atrial Flutter Drug Dosage ▸ Flecainide (class I, level of evidence A) ▸ Oral: 200 to 300 mg ▸ Intravenous: 1.5 to 3.0 mg/kg, over 10 to 20 min ▸ Ibutilide (class I, level of evidence A) ▸ Intravenous: 1 mg over 10 min, repeat 1 mg if necessary ▸ Propafenone (class I, level of evidence A) ▸ Oral: 600 mg ▸ Intravenous: 1.5 to 2.0 mg/kg, over 10 to 20 min ▸ Amiodarone (class IIa, level of evidence A) ▸ Oral: Inpatient ▸ 1.2 to 1.8 g per day in divided dose until a maximum of 10 g ▸ Followed by a maintenance dose of 200 to 400 mg per day or 30 mg/kg Outpatient ▸ 600 to 800 mg per day divided dose until a maximum of 10 g ▸ Followed by a maintenance dose of 200 to 400 mg per day ▸ Intravenous: 5 to 7 mg/kg, over 30 to 60 min Followed by 1.2 to 1.8 g per day continuous IV OR 5 to 7 mg/kg, in divided oral doses until a maximum of 10 g Followe by a maintenance dose of 200 to 400 mg per day

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

• CHADS2 score
  • Congestive heart failure - 1
  • Hypertension -1
  • Age > 75 -1
  • Diabetes Mellitus -1
  • Stroke or TIA - 2
    • Score > 2 anticoagulate
    • Score < 2 Aspirin may be sufficient
• CHA2DS2 VASc score
  • Congestive heart failure - 1
  • Hypertension -1
  • Age > 75 - 2
  • Diabetes Mellitus -1
  • Stroke or TIA - 2
  • Vascular disease - 1
  • Age - 65 -74
  • Sex - Female
    • Score 0 low risk, no anticoagulation or aspirin 81-324
    • Score 1, moderate risk, oral anticoagulation or Aspirin
    • Score 2 or more, oral anticoagulation

References

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