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

Heart Rate Control

Shown below is a table summarizing the list of recommended agents for control of heart rate and their dosages.

Heart Rate Control in Acute Setting Drug Loading dose Maintenance dose Heart rate control in patients without accessory pathway ▸ Esmolol (class I, level of evidence C) ▸ 500 mcg/kg IV over 1 min ▸ 60 to 200 mcg/kg/min IV ▸ Propanolol (class I, level of evidence C) ▸ 0.15 mg/kg IV ▸ NA ▸ Metoprolol (class I, level of evidence C) ▸ 2.5 to 5 mg IV bolus over 2 min; up to 3 doses ▸ NA ▸ Diltiazem (class I, level of evidence B) ▸ 0.25 mg/kg IV over 2 min ▸ 5 to 15 mg/h IV ▸ Verapamil (class I, level of evidence B) ▸ 0.075 to 0.15 mg/kg IV over 2 min ▸ NA Heart rate control in patients with accessory pathway ▸ Amiodarone (class IIa, level of evidence C) ▸ 150 mg over 10 min ▸ 0.5 to 1 mg/min IV Heart Rate Control in patients with heart failure and without accessory pathway ▸ Digoxin (class I, level of evidence B) ▸ 0.25 mg IV each 2 h, up to 1.5 mg ▸ 0.125 to 0.375 mg daily IV or orally ▸ Amiodarone (class IIa, level of evidence C) ▸ 150 mg over 10 min ▸ 0.5 to 1 mg/min IV Heart Rate Control in Non Acute Setting and Long Term Maintenance Heart rate control ▸ Metoprolol (class I, level of evidence C) ▸ 25 to 100 mg twice a day, orally ▸ 25 to 100 mg twice a day, orally ▸ Propanolol (class I, level of evidence C) ▸ 80 to 240 mg daily in divided doses, orally ▸ 80 to 240 mg daily in divided doses, orally ▸ Verapamil (class I, level of evidence B) ▸ 120 to 360 mg daily in divided doses, orally ▸ 120 to 360 mg daily in divided doses, orally ▸ Diltiazem (class I, level of evidence B) ▸ 120 to 360 mg daily in divided doses, orally ▸ 120 to 360 mg daily in divided doses, orally Heart Rate Control in patients with heart failure and without accessory pathway ▸ Digoxin (class I, level of evidence B) ▸ 0.5 mg by mouth daily ▸ 0.125 to 0.375 mg daily, orally ▸ Amiodarone (class IIb, level of evidence C) ▸ 800 mg daily for 1 week, orally 600 mg daily for 1 week, orally 400 mg daily for 4 to 6 week, orally ▸ 200 mg daily, orally

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

Antiarrhythmic Therapy

Maintenance of Sinus Rhythm ▸ Amiodarone (100 to 400 mg) OR ▸ Disopyramide (400 to 750 mg) OR ▸ Dofetilide (500 to 1000 mcg) OR ▸ Flecainide (200 to 300 mg) OR ▸ Procainamide (1000 to 4000 mcg) OR ▸ Propafenone (450 to 900 mg) OR ▸ Quinidine (600 to 1500 mg) OR ▸ Sotalol (160 to 320 mg)

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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