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Updated: Dec 6 2021

Atrial Flutter

Images flutter.jpg
  • Snapshot
    • A 64-year-old woman presents to the emergency room for several hours of lightheadedness and palpitations. Her past medical history includes hypertension, mitral valve regurgitation, and chronic obstructive pulmonary disease. On physical exam, her pulse is around 150/min. An electrocardiogram is administered, revealing a narrow complex tachycardia and sawtooth-like waves in leads II, III, and aVF.
  • Introduction
    • Clinical definition
      • a supraventricular tachycardia characterized by a
        • “sawtooth” appearance, regular rhythm
        • some atrioventricular (AV) node conduction block
    • Associated conditions
      • chronic obstructive lung disease
      • pulmonary embolism
      • thyrotoxicosis
      • alcohol use
      • mitral valve disease
  • Epidemiology
    • Risk factors
      • chronic lung disease
      • heart disease
  • Etiology
    • Pathogenesis
      • large re-entrant circuit, typically in the right atrium
  • Presentation
    • Symptoms
      • syncope
      • palpitations
      • fatigue
      • poor exercise tolerance
    • Physical exam
      • pulse is often around 150/min
      • blood pressure may or may not be decreased
  • Imaging
    • Transthoracic echocardiography (TTE)
      • indications
        • initial imaging for evaluation of atrial size and function
        • may also help diagnosis any valvular disease or thrombus
  • Studies
    • Electrocardiogram (ECG)
      • indication
        • all patients
      • findings
        • narrow complex tachycardia
        • ventricular rate 125-150/min
        • regular atrial rate 250-300/min (usually a 2:1 AV block)
        • flutter waves or “sawtooth” waves in leads II, III, and aVF
    • Adenosine administration
      • indication
        • if ECG is unclear
          • adenosine transiently blocks atrioventricular node
          • atrial flutter is more easily diagnosed on ECG
    • Making the diagnosis
      • based on clinical presentation and ECG
  • Differential
    • Atrial fibrillation
      • distinguishing factor
        • irregularly irregular rhythm
    • Multifocal atrial tachycardia (MAT)
      • distinguishing factor
        • irregularly irregular rhythm with discrete polymorphic P waves
  • Treatment
    • Management approach
      • treatment for atrial flutter is the same as atrial fibrillation
        • except that catheter ablation is a definitive therapy for atrial flutter
    • Medical
      • rate control
        • indication
          • all patients
        • drugs
          • calcium channel blockers
          • β-blockers
          • digoxin
      • rhythm control
        • indication
          • for patients who are contraindicated to catheter ablation therapy
      • anticoagulation
        • indication
          • once rate has been controlled
          • for patients who meet the criteria according to the CHA2DS2-VASc score
        • drugs
          • aspirin
          • warfarin
          • dabigatran
          • rivaroxaban
          • apixaban
    • Non-operative
      • synchronized cardioversion
        • indication
          • unstable patients
    • Operative
      • catheter ablation
        • indication
          • definitive treatment
        • outcomes
          • often superior in the long-term to therapies targeting rate-control or rhythm-control
  • Complications
    • Embolization
    • Heart failure
  • Prognosis
    • Depends on underlying comorbidities
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