From the Guidelines
Atrial flutter with a heart rate of tachycardia is a significant finding on an electrocardiogram (EKG) that requires immediate attention to prevent complications such as thromboembolism and tachycardia-induced cardiomyopathy. The presence of atrial flutter can be a persistent rhythm that may require electrical cardioversion or radiofrequency catheter ablation for termination, as noted in the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1.
Key Considerations
- Atrial flutter may be misdiagnosed as atrial fibrillation when atrial activity is prominent on the ECG, and vice versa 1.
- The relationship between atrial fibrillation and atrial flutter is complex, with atrial flutter often arising during treatment with antiarrhythmic agents prescribed to prevent recurrent atrial fibrillation 1.
- Atypical flutter, or non-cavotricuspid isthmus-dependent macroreentrant atrial tachycardia, describes macroreentrant atrial tachycardias that are not one of the typical forms of atrial flutter that use the cavotricuspid isthmus 1.
Management Approach
- Immediate rate control is crucial to prevent complications, and intravenous metoprolol 5 mg every 5 minutes, up to 3 doses, can be used to target a heart rate below 100 bpm.
- If beta-blockers are contraindicated, consider diltiazem 0.25 mg/kg IV over 2 minutes.
- Once the rate is controlled, initiate anticoagulation with heparin or low molecular weight heparin, followed by oral anticoagulation (e.g., apixaban 5 mg twice daily) if flutter persists beyond 48 hours.
- Arrange for electrical cardioversion within 48 hours if rhythm doesn't spontaneously convert.
- Long-term management may include catheter ablation for recurrent flutter, as noted in the 2014 AHA/ACC/HRS guideline 1.
Monitoring and Follow-up
- Continuous cardiac monitoring is essential during initial management to track rate control and detect any rhythm changes.
- Regular follow-up with a cardiologist is necessary to monitor the effectiveness of treatment and adjust the management plan as needed.
From the FDA Drug Label
Among patients with atrial flutter, 53% receiving 1 mg ibutilide fumarate and 70% receiving 2 mg ibutilide fumarate converted, compared to 18% of those receiving sotalol Conversion of atrial flutter/ fibrillation usually (70% of those who converted) occurred within 30 minutes of the start of infusion and was dose related. For these atrial arrhythmias, ibutilide was more effective in patients with flutter than fibrillation ( ≥ 48% vs ≤ 40%). Among patients with atrial flutter, conversion rates at 1.5 hours were: placebo, 4%; 0.25 mg ibutilide fumarate, 56%; 0.5 mg ibutilide fumarate, 61%; and 1 mg ibutilide fumarate, 78%.
The significance of atrial flutter on an electrocardiogram (EKG) with a heart rate of tachycardia is that it is a type of arrhythmia that can be converted to normal sinus rhythm with medication, such as ibutilide. The conversion rate of atrial flutter to normal sinus rhythm is higher than that of atrial fibrillation, with a conversion rate of 53-78% within 1.5 hours of infusion, depending on the dose of ibutilide [ 2 ]. Key points include:
- Conversion rates: 53-78% for atrial flutter, depending on the dose of ibutilide
- Time to conversion: usually within 30 minutes of the start of infusion
- Effectiveness: ibutilide is more effective in patients with flutter than fibrillation [ 2 ]
From the Research
Significance of Atrial Flutter on an EKG
Atrial flutter is a type of supraventricular tachycardia characterized by a rapid, regular atrial rhythm 3, 4, 5. On an electrocardiogram (EKG), atrial flutter is typically represented by a sawtooth or flutter wave pattern, with a heart rate that can range from 250 to 350 beats per minute 6.
Heart Rate Control in Atrial Flutter
The goal of treatment for atrial flutter is to control the ventricular rate, which can be achieved through the use of antiarrhythmic medications or cardioversion 3, 4, 5. The choice of treatment depends on the patient's symptoms, medical history, and the presence of any underlying heart conditions. For example, beta-blockers or non-dihydropyridine calcium channel blockers are often used as first-line therapy for rate control in patients with atrial flutter 3, 5.
Tachycardia and Atrial Flutter
Tachycardia, or a rapid heart rate, is a common symptom of atrial flutter 3, 4, 5. In patients with atrial flutter, the ventricular rate can be rapid, leading to symptoms such as palpitations, shortness of breath, and fatigue 6. The treatment of tachycardia in atrial flutter typically involves the use of antiarrhythmic medications or cardioversion to slow the ventricular rate and restore a normal sinus rhythm 3, 4, 5.
Key Points
- Atrial flutter is a type of supraventricular tachycardia characterized by a rapid, regular atrial rhythm 3, 4, 5
- The goal of treatment for atrial flutter is to control the ventricular rate 3, 4, 5
- Beta-blockers or non-dihydropyridine calcium channel blockers are often used as first-line therapy for rate control in patients with atrial flutter 3, 5
- Tachycardia is a common symptom of atrial flutter, and treatment typically involves the use of antiarrhythmic medications or cardioversion to slow the ventricular rate and restore a normal sinus rhythm 3, 4, 5