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Key Features

  • Rapid, regular tachycardia presenting classically with 2 to 1 block in the AV node and ventricular heart rate of 150 beats/min; ECG shows "sawtooth" pattern of atrial activity (rate 300 beats/min)

  • Stroke risk should be considered equivalent to that with atrial fibrillation

  • Catheter ablation is highly successful and is considered the definitive treatment for typical atrial flutter

  • Less common than atrial fibrillation

  • May occur in patients with structurally normal hearts but is more commonly seen in patients with

    • Chronic obstructive pulmonary disease (COPD)

    • Valvular or structural heart disease

    • Atrial septal defect

    • Surgically repaired congenital heart disease

Clinical Findings

  • Typical presenting symptoms include

    • Palpitations

    • Fatigue

    • Mild dizziness

  • Symptoms and signs of heart failure (dyspnea, exertional intolerance, edema) due to tachycardia-induced cardiomyopathy may be presenting complaints if arrhythmia is unrecognized for prolonged time

Diagnosis

  • ECG typically demonstrates a "sawtooth" pattern of atrial activity in the inferior leads (II, III, and AVF)

  • The reentrant circuit generates atrial rates of 250–350 beats/min, usually with transmission of every second, third, or fourth impulse through the AV node to the ventricles

Treatment

  • Initially, digoxin, a β-blocker, or a calcium channel blocker (Table 10–11) is used for rate control; conversion to sinus rhythm may result

  • If not, ibutilide (1–2 mg) converts atrial flutter to sinus rhythm in ~50–70% of patients within 60–90 min

  • Electrical cardioversion (25–50 J) is effective in ~90% of patients

  • Precardioversion anticoagulation is not necessary for atrial flutter of < 48 h duration except in the setting of mitral valve disease

  • Anticoagulation should be continued for at least 4 weeks after electrical or chemical cardioversion and longer in patients with risk factors for thromboembolism

  • If atrial flutter is recurrent, consider radiofrequency catheter ablation of the reentrant circuit

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