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atrial flutter

Etiology: 1) may occur in otherwise healthy patients, but also occurs in any of those conditions that predispose to atrial fibrillation 2) acute alcohol ingestion (holiday heart syndrome) most common cause 3) heart disease common a) hypertension (hypertensive heart disease0 b) hypoxia & ischemic heart disease c) coronary artery disease d) myocardial infarction e) congestive heart failure f) cardiomyopathy g) valvular heart disease - rheumatic heart disease h) pericarditis i) congenital heart dieases j) s/p open heart surgery 4) pulmonary disease - pulmonary embolus - chronic obstructive pulmonary disease 5) drug toxicity a) theophylline intoxication b) digitalis toxicity 6) endocrinopathies a) hyperthyroidism b) pheochromocytoma c) diabetes mellitus 7) infections 8) electrolyte abnormalities 9) obesity Epidemiology: - more common in men than women - mean age of onset is 65 years in men, 75 years in women [7] Pathology: - atrial flutter results from a single macro re-entry circuit within the right atrium - the re-entry circuit involves only atrial tissue around functional or structural barriers to conduction Clinical manifestations: 1) similar to atrial fibrillation 2) may be asymptomatic 3) palpitations 4) dizziness 5) dyspnea Complications: - risk of arterial thromboembolism < atrial fibrillation Special laboratory: - electrocardiogram - regular undulation (sawtooth pattern) in the baseline, most notable in V1, & in inferior leads (II, III, avF) - atrial rate is 280-350/min (250-300/min [3]) in type 1 (common) & 350-450 in type 2 (uncommon) - RR interval may be regular, reflecting a 2:1 or 3:1 block (150 & 100 beats/min +/- 15), or may be variable, relecting Wenckebach periodicity - rate may be slowed by class Ia or Ic anti-arrhythmic agents Management: 1) Caveat - may be difficult to distinguish cardiogenic tachycardia (suppress) from tachycardia due to physiological needs (allow) - assess intravascular volume & other noncardiac determinants of a rapid ventricular response prior to treatment [5] 2) cardioversion a) synchronous DC cardioversion (50 joules) b) chemical cardioversion 1] pharmacologic agents - class 1A, 1C or 3 antiarrhythmic agents 2] conversion & maintenance of sinus rhythm c) indications - patient is unstable - mitral stenosis - mitral regurgitation 3) rapid atrial pacing 4) AV nodal blocking agents a) Ca+2-channel antagonists b) beta-blocker c) digoxin: preferred agent in patients with LV systolic dysfunction 5) most cases can be cured with transvenous radiofrequency catheter ablation [3,4] - definitive treatment [3] - rate control & therapeutic anticoagulation are required for a minimum of 4 weeks prior to cardioversion if duration of atrial flutter > 48 hours [7] 6) anticoagulation generally unnecessary after successful catheter ablation

Related

atrial fibrillation (AF) atrial tachycardia

General

supraventricular arrhythmia

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References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 146
  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 272
  3. Medical Knowledge Self Assessment Program (MKSAP) 11, 18, 19. American College of Physicians, Philadelphia 1998, 2018, 2022 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  4. Da Costa A et al, Results for the Loire-Ardeche-Drome-Isere-Puy-de-Dome (LAPID) Trial on atrial flutter, a multicentric prospective randomized study comparing amiodarone and radiofrequency ablation after the first episode of symptomatic atrial flutter. Circulation 2006, 114:1676 PMID: 17030680 - Wyse DG Transvenous radiofrequency catheter ablation for atrial flutter and atrial fibrillation. The end of the beginning? Circulation 2006, 114:1670 PMID: 17043175
  5. Scheuermeyer FX et al. Emergency department patients with atrial fibrillation or flutter and an acute underlying medical illness may not benefit from attempts to control rate or rhythm. Ann Emerg Med 2014 Nov 6 PMID: 25441768 http://www.annemergmed.com/article/S0196-0644%2814%2901298-0/abstract
  6. Writing Committee Members, Heidenreich PA, Solis P, Estes NA 3rd et al 2016 ACC/AHA Clinical Performance and Quality Measures for Adults With Atrial Fibrillation or Atrial Flutter. A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol. 2016;() PMID: 27364541 https://content.onlinejacc.org/article.aspx?articleID=2531644 - Heidenreich PA, Solis P, Mark Estes NA 3rd et al 2016 ACC/AHA Clinical Performance and Quality Measures for Adults With Atrial Fibrillation or Atrial Flutter: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Circ Cardiovasc Qual Outcomes. 2016 Jun 27. pii: HCQ.0000000000000018. PMID: 27354018
  7. Rosenthal L, Rottman JN Medscape: Atrial Flutter. https://emedicine.medscape.com/article/151210-overview