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 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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