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Atrial Flutter

For further information, see CMDT Part 12-09: Atrial Flutter

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 occur 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 beta-blocker, or a calcium channel blocker (Table 12–1) 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 minutes

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

  • Precardioversion anticoagulation is not necessary for atrial flutter of < 48 hours 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

Table 12–1.Antiarrhythmic medications (listed in alphabetical order within class).
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Table 12–1. Antiarrhythmic medications (listed in alphabetical order within class).
Agent Intravenous Dosage Oral Dosage Therapeutic Plasma Level Route of Elimination Side Effects
Class Ia: Action: Sodium channel blockers: Depress phase 0 depolarization; slow conduction; prolong repolarization.
Indications: Supraventricular tachycardia, ventricular tachycardia, symptomatic ventricular premature beats.
Disopyramide  

Immediate release: 100–200 mg every 6 hours

Sustained release: 200–400 mg every 12 hours

 2–8 mg/mL Renal Urinary retention, dry mouth, markedly ↓ LVF, QT prolongation
Procainamide

Loading: 10–17 mg/kg at 20–50 mg/min

Maintenance: 1–4 mg/min

 50 mg/kg/day in divided doses every 4 hours (short-acting) 4–10 mg/mL; NAPA (active metabolite), 10–20 mcg/mL Renal  
Quinidine 6–10 mg/kg (intramuscularly or intravenously) over 20 minutes (rarely used parenterally) 324–648 mg every 8 hours 2–5 mg/mL Hepatic GI, ↓ LVF, ↑ Dig
Class Ib: Action: Shorten repolarization.
Indications: Ventricular tachycardia, prevention of ventricular fibrillation, symptomatic ventricular premature beats.
Lidocaine

Loading: 1 mg/kg

Maintenance: 1–4 ...

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