Atrial Flutter (A-Flutter)

David Ray Velez, MD

A Regular Organized Rhythm Caused by an Atrial Reentrant Circuit

EKG Pattern

Atrial Flutter

Classification

Typical (Type I) Atrial Flutter: The Reentry Circuit Involves the Cavo-Tricuspid Isthmus (CVI)
- Anticlockwise Reentry: Produces Inverted Flutter Waves in the Inferior Leads (II, III, and aVF) with Positive Flutter Waves in V1 (Most Common – 90%)
- Clockwise Reentry: Produces Positive Flutter Waves in the Inferior Leads (II, III, and aVF)with Inverted Flutter Waves in V1
Atypical (Type II) Atrial Flutter: Does Not Involve the Cavo-Tricuspid Isthmus, Includes Any Other Flutter Pattern

Complications

Impaired Atrial Systolic Function (“Atrial Kick”) – Decreased Ventricular Filling
Increases Risk for Thromboembolism Formation within the Left Atrium
- Risk for Stroke or Other Ischemic Events (Probably Lower Risk than that in Atrial Fibrillation)

Treatment

Unstable: Synchronized Cardioversion (Start with 100 J and Increase to 150 J if Fails)
Stable: Consider Rate Control
- Rate Control is Generally More Difficult than in Atrial Fibrillation
- Indications for Rate Control:
  - Symptomatic
  - Prevent Symptoms if Likely to Be Recurrent
  - Prevent Tachycardia-Mediated Cardiomyopathy
- Preferred Agents:
  - Immediate Control: IV Diltiazem or Esmolol
  - Long-Term Therapy: Oral Diltiazem or Verapamil
  - *See Antiarrhythmic Pharmacology
- Consider Synchronized Cardioversion for Symptomatic Atrial Flutter Episodes – High Success Rates
Chronic Management is Generally Best Treated by Ablation of the Reentrant Circuit

Anticoagulation Indications