What are the key questions to ask a patient with atrial flutter?

Key Questions to Ask a Patient with Atrial Flutter

When evaluating a patient with atrial flutter, systematically obtain information about symptom onset timing, prior arrhythmia episodes, stroke risk factors, bleeding history, cardiovascular comorbidities, and previous treatment responses to guide immediate management decisions regarding cardioversion eligibility and anticoagulation needs. 1

Arrhythmia History and Current Episode

Timing and Duration

• Precise time of symptom onset - Critical for determining if the patient is within the 48-hour window for cardioversion without mandatory pre-procedural anticoagulation 2, 3
• Duration of longest, shortest, and usual prior episodes: categorize as <48 hours, 48 hours to 7 days, 7 days to 3 months, or >3 months 1
• Frequency of prior symptomatic episodes - Patient estimate of average interval between episodes in days 1

Symptom Characteristics

• Current symptoms: palpitations, chest discomfort, dyspnea, lightheadedness, syncope, or exercise intolerance 1, 2
• Hemodynamic stability: assess for signs of instability requiring immediate intervention 2

Prior Treatment History

Previous Cardioversion Attempts

• Successful pharmacological cardioversion - List all generic drug names that previously resulted in absence of atrial flutter 1
• Unsuccessful pharmacological cardioversion - List all drugs that failed 1
• Successful electrical cardioversion - Number of previous transthoracic or transvenous sessions that achieved sinus rhythm 1
• Failed electrical cardioversion attempts - Number of unsuccessful sessions 1

Prior Ablation History

• History of ablation for supraventricular arrhythmia, specifically:
  • Cavotricuspid isthmus ablation for atrial flutter 1, 4
  • Other linear ablation sites 1
  • Energy source used (radiofrequency, cryoablation, ultrasound, laser) 1

Current Management Strategy

• Rate control: pharmacological, nonpharmacological, hybrid, or none 1
• Rhythm control: pharmacological, nonpharmacological, hybrid, or none 1
• Current medications for arrhythmia management 1

Thromboembolic Risk Assessment

Stroke History

• Prior ischemic stroke with etiology (large-artery disease, small-artery/lacunar, embolic, other) and imaging confirmation 1
• Residual deficits: complete recovery, mild-to-moderate deficit, or severe deficit requiring assistance with activities of daily living 1
• History of transient ischemic attack with acute neurological symptoms resolving within 24 hours 1
• Systemic peripheral embolism - Document site and clinical evidence of arterial occlusion 1
• Carotid artery disease with ≥50% stenosis (assessed by ultrasound, MRA, or angiography) 1

CHADS₂ Score Components

Calculate stroke risk by documenting: 2, 3

• Congestive heart failure history 1
• Hypertension 1
• Age ≥75 years 1
• Diabetes mellitus - Duration, treatment method (none, diet, oral agents, insulin) 1
• Prior stroke or TIA (worth 2 points) 1, 3

Hemorrhagic Risk Assessment

Bleeding History

• Intracranial hemorrhage: hemorrhagic stroke conversion, subarachnoid hemorrhage, intracerebral hemorrhage, subdural/epidural hematoma 1
• Residual deficits from intracranial hemorrhage - Current functional status 1
• Other significant hemorrhage - Location, severity, and timing 1

Cardiovascular Comorbidities

Structural Heart Disease

• Valvular heart disease - Type and severity 1
• Prior valve intervention 1
• Heart failure - Current functional class 1
• Myocardial infarction - Timing and location 1
• Hypertrophic cardiomyopathy - Obstructive vs. nonobstructive 1
• Cardiomyopathy with left ventricular ejection fraction <40% 1
• Congenital heart disease - Specific diagnosis and prior repairs 1

Cardiac Rhythm Disorders

• Sinus bradycardia/sick sinus syndrome - Symptoms and manifestations 1
• Atrioventricular block - Highest degree (1st, 2nd Mobitz I/II, advanced, or 3rd degree) 1
• Ventricular arrhythmias requiring cardioversion or antiarrhythmic drugs 1
• Other supraventricular tachycardias - AVNRT, AVRT, atrial tachycardia 1

Cardiac Devices

• Pacemaker: type (single/dual/biventricular chamber), indication, capabilities 1
• Implantable cardioverter-defibrillator: type, indication, capabilities 1

Precipitating Factors and Reversible Causes

Acute Triggers

• Recent cardiac or thoracic surgery 1
• Pericarditis 1
• Pulmonary disease - Active exacerbation or chronic condition 1
• Hyperthyroidism - Symptoms and prior thyroid function tests 1
• Pulmonary congestion on chest radiograph - Associated with higher adverse event risk 3

Family History

• Family history of atrial fibrillation or flutter 1
• Genetic variants or inherited arrhythmia syndromes 1

Clinical Pitfalls to Avoid

Duration uncertainty: If the patient cannot confidently confirm symptom onset <48 hours ago, treat as if duration is >48 hours and require 3 weeks of therapeutic anticoagulation before cardioversion 2. The single most important question is precise timing of onset, as this determines immediate management pathway 2, 3.

Atrial flutter vs. atrial fibrillation: Document which arrhythmia is present, as they may coexist or alternate, though management principles are similar 1, 4.

High-risk features: Longer duration from onset, previous stroke/TIA, and pulmonary congestion predict higher 30-day adverse events 3.