Atrial Flutter

Symptoms of atrial flutter depend primarily on ventricular rate and the nature of any underlying heart disorder. If ventricular rate is < 120 beats/minute and regular, there are likely to be few or no symptoms. Faster rates and variable AV conduction usually cause palpitations, and decreased cardiac output may cause symptoms of hemodynamic compromise (eg, chest discomfort, dyspnea, weakness, syncope). Close inspection of the jugular venous pulse reveals flutter a waves.

The diagnosis of atrial flutter is by electrocardiography (ECG). In typical flutter, ECG shows continuous and regular atrial activation with a sawtooth pattern, most obvious in leads II, III, and aVF (see figure Atrial flutter Atrial flutter ).

Carotid sinus massage can increase AV block and better expose the typical flutter waves. A similar response may follow pharmacologic AV nodal blockade (eg, with adenosine), but such therapy does not terminate atrial flutter.

Treatment of atrial flutter focuses on ventricular rate control, rhythm control, and prevention of thromboembolism.

Pharmacologic rate control is more difficult to achieve in atrial flutter than in atrial fibrillation. Thus, for most patients, electrical conversion (using synchronized cardioversion Cardiac Resynchronization Therapy (CRT) The need for treatment of arrhythmias depends on the symptoms and the seriousness of the arrhythmia. Treatment is directed at causes. If necessary, direct antiarrhythmic therapy, including antiarrhythmic... read more or overdrive pacing) is the treatment of choice for an initial episode and is mandatory with 1:1 AV conduction or hemodynamic compromise. Typically, low-energy (50 joules) conversion is effective. Anticoagulation Prevention of thromboembolism Atrial fibrillation is a rapid, irregularly irregular atrial rhythm. Symptoms include palpitations and sometimes weakness, effort intolerance, dyspnea, and presyncope. Atrial thrombi may form... read more , as in atrial fibrillation, is necessary before cardioversion.

If medication is used to restore sinus rhythm, rate must first be controlled with beta-blockers or nondihydropyridine calcium channel blockers (eg, verapamil, diltiazem). Many of the antiarrhythmic drugs Medications for Arrhythmias The need for treatment of arrhythmias depends on the symptoms and the seriousness of the arrhythmia. Treatment is directed at causes. If necessary, direct antiarrhythmic therapy, including antiarrhythmic... read more that can restore sinus rhythm (especially class Ia and Ic) can slow atrial flutter, shorten AV nodal refractoriness (by their vagolytic effects), or do both enough to allow 1:1 conduction with paradoxical increase in ventricular rate and hemodynamic compromise. These medications may be used for long-term maintenance as required to prevent recurrence.

An antitachycardia pacing system is an alternative to long-term use of antiarrhythmics and is a rare therapy used in patients with an independent indication for pacing who are ineligible or in whom other approaches to rhythm control have failed. Also, ablation procedures Ablation for Cardiac Arrhythmia The need for treatment of arrhythmias depends on the symptoms and the seriousness of the arrhythmia. Treatment is directed at causes. If necessary, direct antiarrhythmic therapy, including antiarrhythmic... read more designed to interrupt the atrial reentrant circuit may effectively prevent atrial flutter, particularly typical atrial flutter.

To prevent thromboembolism, patients with chronic or recurrent atrial flutter require an oral anticoagulant (warfarin titrated to an INR of 2 to 3, a direct thrombin inhibitor, or a factor Xa inhibitor). The choice among the therapies is based on the same considerations as in the treatment of atrial fibrillation Treatment Atrial fibrillation is a rapid, irregularly irregular atrial rhythm. Symptoms include palpitations and sometimes weakness, effort intolerance, dyspnea, and presyncope. Atrial thrombi may form... read more .