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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Regular ventricular rate of 75–150 bpm

  • Irregular ventricular response secondary to variable atrioventricular (AV) block, usually induced by medication

  • Prominent neck vein pulsations of about 300/min

  • Flutter waves ("saw-tooth" in inferior leads) on ECG at rate of approximately 300/min

GENERAL CONSIDERATIONS

  • Usually associated with organic heart disease more often than atrial fibrillation

  • Typical atrial rate is 300 bpm, but 1:1 ventricular conduction is rare

  • Ventricular rate is dependent on AV nodal conduction

  • If flutter is suspected but not clearly seen on surface ECG, vagal maneuvers or IV adenosine can help unmask flutter waves

  • Up to 33% of patients may experience atrial flutter after bypass surgery

  • Cavotricuspid isthmus-dependent counterclockwise rotation (negative flutter waves in ECG inferior leads and positive in V1) is the most common

  • Isthmus-dependent, clockwise flutter also occurs (positive waves in lead II)

  • Non–isthmus-dependent atypical variety is uncommon, unless patient has history of prior ablations or cardiac surgery

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Dizziness

  • Palpitations

  • Angina

  • Dyspnea

  • Weakness

  • Fatigue

  • Occasionally syncope

  • Many of the symptoms are heart rate dependent

PHYSICAL EXAM FINDINGS

  • Prominent neck vein pulsations of about 300 bpm

  • Variable S1 intensity

DIFFERENTIAL DIAGNOSIS

  • Atrial tachycardia

  • Paroxysmal supraventricular tachycardia

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Thyroid-stimulating hormone

  • Basic metabolic panel

  • Cardiac biomarkers depending on clinical situation

ELECTROCARDIOGRAPHY

  • ECG to document rhythm

  • Ambulatory cardiac monitoring to detect rhythm disturbance

  • Event recorder to detect infrequent episodes

IMAGING STUDIES

  • Transthoracic echocardiogram to detect structural heart disease

  • Depending on precipitating causes, chest x-ray or CT scan of the chest

DIAGNOSTIC PROCEDURES

  • Occasionally in those with pacemakers, interrogation of the device may reveal the atrial flutter episodes

TREATMENT

CARDIOLOGY REFERRAL

  • All atrial flutter patients should be referred for cardiology evaluation because the condition is curable with ablation

HOSPITALIZATION CRITERIA

  • All symptomatic patients should be hospitalized

MEDICATIONS

  • Similar to atrial fibrillation, chronic anticoagulation with an oral anticoagulant is indicated for stroke prevention based on the patient’s CHA2DS2-Vasc score

  • Chemical cardioversion with IV ibutilide 1 mg over 10 minutes; may be repeated

  • Flecainide 300 mg or propafenone 600 mg orally as single dose to restore sinus rhythm (used in patients with structurally normal hearts)

  • Rate control with beta blockers, calcium channel blockers, or digoxin either individually or in combination

THERAPEUTIC PROCEDURES

  • Cardioversion can be performed with electrical cardioversion or overdrive pacing (if pacemaker is present)

  • Radiofrequency ablation of typical atrial ...

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