A patient experiences brief palpitations that can be aborted by light pressure over the area where they are felt, while the heart rate remains normal; could this be atrial flutter?

This is unlikely to be atrial flutter based on the clinical description provided.

The ability to terminate palpitations with light pressure (vagal maneuver) combined with a normal heart rate strongly suggests atrioventricular nodal reentrant tachycardia (AVNRT) or another supraventricular tachycardia involving the AV node, not atrial flutter.

Key Clinical Reasoning

Atrial flutter characteristics that don't match this presentation:

• Atrial flutter typically presents with an atrial rate of 240-320 beats per minute with characteristic "sawtooth" flutter waves on ECG 1
• The ventricular response is usually rapid (120-160 bpm with 2:1 AV block) when untreated 2
• Atrial flutter with a normal heart rate is uncommon and typically only occurs with:
  • AV nodal blocking medications (beta-blockers, calcium channel blockers)
  • Intrinsic AV nodal disease
  • Electrolyte disturbances 3

What the clinical picture suggests instead:

The termination by vagal maneuvers (light pressure) is a hallmark feature of re-entrant tachycardias involving the AV node, particularly AVNRT or AVRT 4. These arrhythmias:

• Have abrupt onset and termination (paroxysmal pattern)
• Respond to vagal maneuvers because the AV node is part of the re-entry circuit
• Can present with brief episodes and normal baseline heart rate 5

Critical Diagnostic Steps

What you need to document:

1. 12-lead ECG during the palpitations - This is essential and non-negotiable 2

   • AVNRT: No visible P waves or pseudo-R' waves in V1
   • Atrial flutter: Sawtooth pattern in leads II, III, aVF

2. Event monitor or Holter monitoring if episodes are infrequent 2, 6

   • Two-week event recorder for unpredictable episodes
   • 24-48 hour Holter if daily symptoms

3. Response pattern documentation:

   • Does it terminate abruptly with vagal maneuvers? → Suggests AVNRT/AVRT
   • Does the rate simply slow temporarily? → Could suggest atrial flutter with variable AV block

Common Pitfall

Do not assume atrial flutter can be easily terminated by vagal maneuvers. While vagal maneuvers may transiently slow the ventricular response in atrial flutter by increasing AV block, they rarely terminate the arrhythmia 1. The atrial flutter circuit continues independently of AV nodal conduction. In contrast, AVNRT and AVRT terminate completely with successful vagal maneuvers because the AV node is an integral part of the re-entry circuit 4, 5.

Bottom Line

The clinical scenario described—brief palpitations terminated by light pressure with normal heart rate—is characteristic of AVNRT or AVRT, not atrial flutter. Obtain ECG documentation during symptoms to confirm the diagnosis. If atrial flutter is ultimately documented, the normal heart rate and vagal termination would suggest either concurrent AV nodal disease or medication effect that requires further evaluation 3.