Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ 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 ... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.