Atrial Flutter

- See: A. Fib 
- Discussion:  
- atrial flutter may be assoc w/ sick sinus syndrome, hypoxia, Pericarditis, valvular heart dz, and less commonly, acute myocardial infarction; 
- orginates in a single atrial ectopic focus; 
- flutter waves occur in rapid succession & are identical; 
- flutter waves have "saw tooth" appearance & do not have a flat baseline; 
- usually there are several "flutter waves" before each QRS
- typically 2:1 or 4:1, or less often 3:1 or 5:1; - typically 2:1 in pts not on Digoxin
- Management: Stable A. flutter: 
- r/o WPW as a predisposing cause; 
- as with A.fib inital goal is rate control, rather than restoration of sinus; 
- mild symptoms, then attempt control rate w/ pharmological therapy first; 
- ventricular rate can be slowed with digitalis, verapamil, or Beta blocking agents; (the latter 2 may exacerbate CHF) 
- carotid massage may convert 2:1 block to 4:1 block; 
- flutter waves may not be seen at 2:1 conduction, and this rhythm is often mistaken for PAT or sinus tachycardia; 
- carotid sinus massage to block just one beat to 3:1 conduction will clearly show flutter waves; 
- once rate is controlled, pt is placed on Type I antiarrhythmic agent such as quinidine or procainamide to convert flutter; 
- these agents are not useful in the management of new onset atrial fib and flutter, because they may increase rate of ventricular response; 
- these agents should be only used after complete digitalization; 
- Unstable A. flutter (pt awake); 
- requires Digoxin loading, but do not wait 30 min for IV Digoxin to work; 
- consider either IV B blocker or Ca blocker along w/ IV digitalization; 
- Propanolol 0.5-1 mg IV q 5-8 min, then 10-20 mg PO q6hr 
- Verapamil: 5 mg IV q10-15 min x 3 doses, then 80 mg PO q8hr 
- Diltiazem 
- Unstable A. flutter (pt unconscious); 
- w/ hypotension, ischemic pain, or CHF, pt requires Cardioversion
- is one of the easiest rhythms to convert to sinus rhythm; 
- Cardioversion may require less than 50 Joules, but atrial flutter often converts to atrial fibrillation w/ low energy discharges (5-10 J); 
- Resistant A. fib; 
- if 3 days of quinidine does not convert the rhythm to NSR; 
- then hold Digoxin for 24 hrs, and attempt DC conversion; 
- Chronic A. flutter: 
- maintenance of NSR is unlikely if A. fib has continued for > 6 months; 
- DC conversion is unlikely to work - consider Anticoagulation: (see Heparin

Preliminary report of the Stroke Prevention in Atrial Fibrillation Study.  
Original Articles: The Effect of Low-Dose Warfarin on the Risk of Stroke in Patients with Nonrheumatic Atrial Fibrillation
Meta-analysis of the effectiveness of prophylactic drug therapy in preventing supraventricular arrhythmia early after coronary artery bypass grafting.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, December 19, 2011 3:13 pm