Home Books Current Medical Diagnosis and Treatment 2020

10-33: Atrial Flutter

Thomas M. Bashore; Christopher B. Granger; Kevin P. Jackson; Manesh R. Patel

ESSENTIALS OF DIAGNOSIS

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.

GENERAL CONSIDERATIONS

Atrial flutter is less common than fibrillation. It may occur in patients with structurally normal hearts but is more commonly seen in patients with COPD, valvular or structural heart disease, ASD, or surgically repaired congenital heart disease.

CLINICAL FINDINGS

Patients typically present with complaints of palpitations, fatigue, or mild dizziness. In situations where the arrhythmia is unrecognized for a prolonged period of time, patients may present with symptoms and signs of heart failure (dyspnea, exertional intolerance, edema) due to tachycardia-induced cardiomyopathy. The 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 (eFigures 10–80, 10–81, and 10–82).

eFigure 10–80.

Various ECG patterns produced by atrial flutter. A: A trial flutter showing the typical sawtoothed pattern is present. The atrial rate is unusually slow at about 220/min. The flutter waves deform the ST segments, mimicking ST elevation (arrows). Careful attention to the variation in QRST morphology should provide a clue to the correct diagnosis. The ventricular rate shows group beating characteristic of type I (Wenckebach) second-degree block of the flutter impulses. Type I atrioventricular (AV) block of flutter impulses that occurs within the AV node has no clinical significance since the AV nodal block often occurs in response to rapid atrial rates. B: F lutter waves superimposed upon QRS complexes deform them (arrows), mimicking an intermittent intraventricular conduction delay. Careful measurement of the atrial rate provides evidence that the wave deforming the downstroke of the QRS complexes is a flutter wave. Note the unusually slow flutter rate of about 190/min. C: F lutter waves having the same amplitude as the QRS complexes (arrows) mimic a period of ventricular asystole. Simultaneous recording of other leads will more clearly define the QRS complexes. D: Flutter waves superimposed upon the downstrokes of the QRS complexes (arrows) mimic ST-segment depression. E: Flutter waves occurring at the ends of the QRS complexes (arrows) mimic a Qr configuration and an intraventricular conduction delay. Since the ventricular rate is regular at 150/min, the diagnosis of atrial flutter with 2:1 AV conduction should always be strongly considered. (Reproduced, with permission, from Goldschlager N, Goldman MJ. Principles of Clinical Electrocardiography, 13th ed. Originally published by Appleton & Lange. Copyright © 1989 by The McGraw-Hill Companies, Inc.)