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 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.

• Carbon monoxide poisoning
• Myocardial infarction
• Pulmonary embolism

Common Causes

• Acute coronary syndromes
• Cardiomyopathy
• Congenital heart disease
• Hypertensive heart disease
• Hyperthyroidism
• Mitral valve disease

Management

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 ❑ Pulmonary embolism ❑ Coronary thrombosis ❑ Trauma
								❑ 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.

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.

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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