Atrial flutter: Maintenance of sinus rhythm
- Jordan M Prutkin, MD, MHS, FHRS
Jordan M Prutkin, MD, MHS, FHRS
- Associate Professor of Medicine, Division of Cardiology, Electrophysiology Section
- University of Washington
Atrial flutter is a relatively common supraventricular arrhythmia that can cause unacceptable symptoms and can promote atrial thrombus formation with the potential for systemic embolization. Restoration and maintenance of sinus rhythm improves symptoms and decreases the risk of embolization if atrial flutter recurrence does not occur. (See "Overview of atrial flutter", section on 'Clinical manifestations' and "Embolic risk and the role of anticoagulation in atrial flutter", section on 'Embolic risk'.)
Issues related to the indications and therapeutic options for the maintenance of sinus rhythm in atrial flutter will be reviewed here. Causes of atrial flutter, rate control therapy, the restoration of sinus rhythm after cardioversion, and the role of anticoagulation in atrial flutter are discussed separately. (See "Overview of atrial flutter", section on 'Etiology and risk factors' and "Restoration of sinus rhythm in atrial flutter" and "Embolic risk and the role of anticoagulation in atrial flutter" and "Control of ventricular rate in atrial flutter".)
We attempt to keep most patients with recurrent atrial flutter in sinus rhythm to decrease symptoms, unlike atrial fibrillation (AF) in which rhythm control and rate control are reasonable strategies. In addition, the long-term maintenance of sinus rhythm may decrease the risk of stroke. Rhythm control with either radiofrequency (RF) catheter ablation or antiarrhythmic drug therapy is necessary; in most cases, RF catheter ablation is preferred. Exceptions include individuals identified as having reversible triggers such as pneumonia, hyperthyroidism, and other acute medical problems. (See "Rhythm control versus rate control in atrial fibrillation", section on 'Choice of therapy'.).
Atrial flutter is characterized by rapid, regular atrial depolarizations at a characteristic rate of approximately 300 beats/min. In the absence of rate slowing drugs or atrioventricular (AV) nodal disease, every other depolarization passes through the AV node, and the ventricular rate is usually around 150 beats per minute. Unlike AF, attempts to slow this rate are often unsuccessful or require high doses of rate slowing drugs; thus, the maintenance of sinus rhythm is desirable in most patients to control symptoms. In addition, episodes will often be recurrent unless a reversible cause is present. (See "ECG tutorial: Atrial and atrioventricular nodal (supraventricular) arrhythmias", section on 'Atrial fibrillation and atrial flutter' and "Overview of atrial flutter".)
The discussion in this topic pertains primarily to patients with typical atrial flutter. The pathogenesis of typical atrial flutter makes it highly amendable to curative therapy with radiofrequency (RF) catheter ablation, though atypical flutters may also be cured with RF ablation. Typical (also called isthmus-dependent) atrial flutter utilizes a large macroreentrant pathway in the right atrium, with the left atrium following passively. (See "Electrocardiographic and electrophysiologic features of atrial flutter".)
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- RF CATHETER ABLATION
- - Recurrent flutter or AF
- - Improvement in left ventricular function
- - Quality of life
- RF ablation versus pharmacologic therapy
- PHARMACOLOGIC THERAPY
- PATIENTS WITH ATRIAL FIBRILLATION
- Anticoagulation before RF catheter ablation
- Anticoagulation after RF catheter ablation
- SUMMARY AND RECOMMENDATIONS