Electrocardiographic and electrophysiologic features of atrial flutter
- Jordan M Prutkin, MD, MHS, FHRS
Jordan M Prutkin, MD, MHS, FHRS
- Associate Professor of Medicine, Division of Cardiology, Electrophysiology Section
- University of Washington
- Section Editors
- Peter J Zimetbaum, MD
Peter J Zimetbaum, MD
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Harvard Medical School
- Ary L Goldberger, MD
Ary L Goldberger, MD
- Section Editor — Electrocardiography
- Professor of Medicine
- Harvard Medical School
Atrial flutter (AFL) is an abnormal cardiac rhythm characterized by rapid, regular atrial depolarizations at a typical atrial rate of 250 to 350 beats per minute. There is frequently 2:1 conduction across the atrioventricular (AV) node, meaning that every other atrial depolarization reaches the ventricles. As a result, the ventricular rate is usually one-half the AFL rate in the absence of AV node dysfunction. AFL is classified as typical or atypical based on whether the flutter circuit traverses the cavotricuspid isthmus in the right atrium .
Other topic reviews discuss the clinical aspects of AFL. (See "Overview of atrial flutter" and "Restoration of sinus rhythm in atrial flutter" and "Control of ventricular rate in atrial flutter" and "Atrial flutter: Maintenance of sinus rhythm" and "Embolic risk and the role of anticoagulation in atrial flutter" and "Atrial fibrillation and flutter after cardiac surgery".)
The first classification scheme in 1970 defined atrial flutter (AFL) as “common” or “atypical,” depending on whether the flutter wave had a negative sawtooth pattern in the inferior leads . A few years later, the terms types I and II were created to describe flutter . Type I AFL was classified as a macroreentrant atrial tachycardia, with the most common circuit including the isthmus of tissue between the inferior vena cava (IVC) and tricuspid annulus as a necessary component. Type II AFL was considered unclassified because the mechanisms were not fully understood. Type II AFL was defined as any tachycardia fulfilling the classic electrocardiographic definition of a continuously undulating pattern but not fitting the typical flutter patterns (counterclockwise or clockwise) described in the original classification.
A 2001 working group from Europe and North America tried to reconcile new data from electrophysiology studies and activation mapping . Flutter was defined as a regular tachycardia ≥240 beats/min with no isoelectric baseline between atrial deflections. Typical and reversal typical flutter were characterized, as described below, and all other flutters were atypical.
An American College of Cardiology, American Heart Association, and Heart Rhythm Society guideline on the management of supraventricular tachycardia reaffirmed the classification of AFL into cavo-tricuspid-isthmus (CTI)-dependent (“typical”) versus non-CTI dependent (“atypical”)  and this is the methodology currently used.
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- ELECTROPHYSIOLOGIC FEATURES
- Typical flutters
- Atypical right atrial flutters
- - Lesion macroreentrant tachycardia
- - Nonatriotomy-related right atrial flutter
- - Upper loop reentry
- Atypical left atrial flutters
- - Post-Maze or atrial fibrillation ablation left atrial flutters
- - Left atrial macroreentry
- Atrioventricular node and the ventricular response
- ELECTROCARDIOGRAPHIC FEATURES
- Morphology of the QRS complex
- DIFFERENTIAL DIAGNOSIS