- 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.