Overview of atrial flutter
- Robert Phang, MD, FACC, FHRS
Robert Phang, MD, FACC, FHRS
- Albany Associates in Cardiology
- Jordan M Prutkin, MD, MHS, FHRS
Jordan M Prutkin, MD, MHS, FHRS
- Associate Professor of Medicine, Division of Cardiology, Electrophysiology Section
- University of Washington
- Leonard I Ganz, MD, FHRS, FACC
Leonard I Ganz, MD, FHRS, FACC
- Section Editor — Cardiac Arrhythmias
- Director of Cardiac Electrophysiology
- Heritage Valley Health System
Atrial flutter is an abnormal cardiac rhythm characterized by rapid, regular atrial depolarizations at a characteristic rate of approximately 300 beats/min and a regular ventricular rate of about 150 beats/min in patients not taking atrioventricular (AV) nodal blockers. It can lead to symptoms of palpitations, shortness of breath, fatigue, or lightheadedness, as well as an increased risk of atrial thrombus formation that may cause cerebral and/or systemic embolization.
Atrial flutter occurs in many of the same situations as atrial fibrillation, which is much more common. Atrial flutter may be a stable rhythm or a bridge arrhythmia between sinus rhythm and atrial fibrillation. It may also be associated with a variety of other supraventricular arrhythmias. (See "Epidemiology of and risk factors for atrial fibrillation".)
This topic will summarize key points regarding the causes, clinical presentation, diagnosis, and management approach to patients with atrial flutter. Other topics discuss management issues in detail. (See "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".)
In 2001, the European Society of Cardiology and the North American Society of Pacing and Electrophysiology proposed a classification that takes into consideration both anatomic features and electrophysiologic mechanisms determined at the time of electrophysiologic testing . Type I atrial flutter was classified as a macroreentrant atrial tachycardia (see "Electrocardiographic and electrophysiologic features of atrial flutter"), while type II atrial flutter was considered unclassified because the mechanisms were not fully understood (figure 1) [2,3]. (See "Electrocardiographic and electrophysiologic features of atrial flutter".) Type I was separated from type II on the basis of the flutter rate (240 to 340 beats/min compared to 340 to 440 beats/min in type II), the existence of an excitable gap, the ability to transiently entrain type I but not type II, and the observation that type II can change in a "stepwise" manner to type I. This terminology has grown out of favor due to the relative infrequency of type II atrial flutter (AFL).
Classification has centered on whether the circuit traverses the cavo-tricuspid isthmus (figure 1). This isthmus is the region of right atrial tissue between the orifice of the inferior vena cava and the tricuspid valve annulus (figure 2). If this isthmus is involved, it is called “typical” atrial flutter. The circuit is usually a counterclockwise rotation around the tricuspid valve. If the circuit is clockwise, it is called “reverse” or “clockwise” typical flutter. If this isthmus is not involved, then it is “atypical” atrial flutter. Surgical repair of congenital heart disease may lead to macroreentrant atrial flutter circuits, both typical (cavotricuspid isthmus dependent) and atypical, as patients age; these circuits are usually right atrial and relate to anatomic obstacles and surgical scars (cavotricuspid isthmus, right atriotomy scar, atrial septal defect repair, etc). Incomplete ablation lines created in attempts to cure atrial fibrillation with ablation can promote atypical atrial flutter circuits in the left atrium (mitral flutter, etc).
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- ELECTROPHYSIOLOGIC CLASSIFICATION
- ETIOLOGY AND RISK FACTORS
- CLINICAL MANIFESTATIONS
- History and physical examination
- Chest radiograph
- Additional testing
- DIFFERENTIAL DIAGNOSIS
- GENERAL TREATMENT ISSUES
- Rate control in atrial flutter
- Reversion to NSR
- Maintenance of NSR
- Prevention of systemic embolization
- INFORMATION FOR PATIENTS