Atrial flutter resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hilda Mahmoudi M.D., M.P.H.[2]; Priyamvada Singh, M.D. [3]

Atrial fibrillation resident survival guide Microchapters
Overview
Causes
Diagnosis
Treatment
Heart Rate Control
Pharmacological Cardioverion
Antiarrhythmic Therapy
Anticoagulation Therapy
Do's
Dont's

Overview

Atrial flutter is a reenterant arrhythmia, with atrial rates between 240 and 340/min, with a regular ventricular response and a saw tooth pattern on EKG. While it occurs mostly in patients with structural heart disease, it may also occur in patients with normal heart. It presents with palpitations, dyspnea, fatigue, lightheadedness etc. A typical flutter rhythm on EKG consists of absent P waves, saw tooth pattern in leads II, III and aVF, an atrial rate of 240-340 beats/min and an atrial rate:ventricular rate ratio 2:1 (most commonly). The treatment consists of rate control, anticoagulation therapy and cardioversion if the flutter is well tolerated. In those with poorly tolerated flutter or hemodynamic instability direct DC cardioversion is attempted, followed by rate control therapy.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Atrial flutter can be a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

Management

Diagnostic Approach

Shown below is an algorithm summarizing the initial approach to atrial flutter.

 
Characterize the symptoms:

❑ Asymptomatic
Palpitations
Dyspnea
Fatigue
Chest discomfort
Lightheadedness
Syncope/Presyncope
Tachycardia
❑ Weakness
Characterize the timing of the symptoms:
❑ Onset

❑ First episode
❑ Recurrent

❑ Duration
❑ Frequency
❑ Termination of the episode

❑ Spontaneous
❑ Medication use
❑ Not terminated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
Tachycardia
Hypotension - suggestive of ventricular dysfunction
Diaphoresis
Evidence of congestive heart failure
❑ Flutter waves in jugular vein
❑ Signs of embolization

Pulmonary:

Dyspnea
Tachypnea
Chest pain
Hemoptysis

Arterial:

❑ Cold extremities
❑ Loss of distal pulsations
Pallor of the extremity
❑ Muscle pain/spasm in concerned area
❑ Weakness/lack of movement
Tingling and numbness

❑ Order an ECG
♦ Atrial flutter rhythm

❑ Absent P waves
❑ Atrial rate 240-340 beats/minute
❑ Atrial rate:ventricular rate ratio 2:1 (most commonly)
❑ Saw tooth pattern in leads II, III, and aVF

Atrial flutter and RBBB.jpg ♦ Other signs on ECG

Left ventricular hypertrophy
Preexcitation
Bundle branch block
❑ Previous myocardial infarction
❑ Other types of arrhythmias
 
 
 
 
 
 
 
 
 

Order labs:
❑ Order a transthoracic echocardiogram
Holter monitoring
❑ Exercise testing
❑ Order blood tests (if Atrial flutter has not been investigated before)

Thyroid function
Renal function
Hepatic function
 


Therapeutic Approach

Shown below is an algorithm summarizing the therapeutic approach to atrial flutter.[3]

 
 
 
 
 
 
Atrial flutter
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unstable
 
 
 
 
 
Stable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Look for the presence of any of these:
Chronic heart failure
Hypotension
Acute myocardial infarction

❑ If present, attempt direct DC cardioversion and then rate control measures as shown in the table below:

ConversionDC cardioversion < 50 J energy with monophasic shocks (class I, level of evidence C)
Rate controlBeta blockers (class IIa, level of evidence C)
or
Verapamil or diltiazem (class IIa, level of evidence C)
or
Digitalis (class IIb, level of evidence C)
or
Amiodarone (class IIb, level of evidence C)
 
 
 
 
 
❑ Administer anticoagulation therapy based on the risk of stroke, if total duration of flutter > 48 hours
❑ Administer rate control therapy as shown in table below:
Rate controlBeta blockers (class IIa, level of evidence C)
or
Verapamil or diltiazem (class IIa, level of evidence C)
or
Digitalis (class IIb, level of evidence C)
or
Amiodarone (class IIb, level of evidence C)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Assess need for therapy to prevent recurrence
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Administer antiarrhythmic therapy to prevent recurrences as shown below:
First episode and well-tolerated atrial flutterCardioversion alone (class I, level of evidence B)
or
Catheter ablation (class IIa, level of evidence B)
Recurrent and well-tolerated atrial flutterCatheter ablation(class I, level of evidence B)
or
Dofetilide (class IIa, level of evidence C)
or
Amiodarone (class IIb, level of evidence C)
or
Sotalol
or
Flecainide
or
Quinidine
or
Propafenone
or
Procainamide
or
Disopyramide
Poorly tolerated atrial flutterCatheter ablation (class I, level of evidence B)
Atrial flutter appearing after use of class Ic agents or amiodarone for treatment of AFCatheter ablation (class I, level of evidence B)
or
Stop current drug and use another (class IIa, level of evidence C)
Symptomatic non–cavotricuspid isthmus-dependent flutter after failed antiarrhythmic therapyCatheter ablation (class IIa, level of evidence B)

❑ Consider Catheter ablation if antiarrhythmic therapy fails
 
 
 
 
 
 
 
 
 
 

Heart Rate Control

Shown below is a table summarizing the list of recommended agents for control of heart rate and their dosages.[4]

Heart Rate Control in Acute Setting
Drug Loading dose Maintenance dose
Heart rate control in patients without accessory pathway
Esmolol
(class I, level of evidence C)
500 mcg/kg IV over 1 min 60 to 200 mcg/kg/min IV
Propanolol
(class I, level of evidence C)
0.15 mg/kg IV NA
Metoprolol
(class I, level of evidence C)
2.5 to 5 mg IV bolus over 2 min; up to 3 doses NA
Diltiazem
(class I, level of evidence B)
0.25 mg/kg IV over 2 min 5 to 15 mg/h IV
Verapamil
(class I, level of evidence B)
0.075 to 0.15 mg/kg IV over 2 min NA
Heart rate control in patients with accessory pathway
Amiodarone
(class IIa, level of evidence C)
150 mg over 10 min 0.5 to 1 mg/min IV
Heart Rate Control in patients with heart failure and without accessory pathway
Digoxin
(class I, level of evidence B)
0.25 mg IV each 2 h, up to 1.5 mg 0.125 to 0.375 mg daily IV or orally
Amiodarone
(class IIa, level of evidence C)
150 mg over 10 min 0.5 to 1 mg/min IV
Heart Rate Control in Non Acute Setting and Long Term Maintenance
Heart rate control
Metoprolol
(class I, level of evidence C)
25 to 100 mg twice a day, orally 25 to 100 mg twice a day, orally
Propanolol
(class I, level of evidence C)
80 to 240 mg daily in divided doses, orally 80 to 240 mg daily in divided doses, orally
Verapamil
(class I, level of evidence B)
120 to 360 mg daily in divided doses, orally 120 to 360 mg daily in divided doses, orally
Diltiazem
(class I, level of evidence B)
120 to 360 mg daily in divided doses, orally 120 to 360 mg daily in divided doses, orally
Heart Rate Control in patients with heart failure and without accessory pathway
Digoxin
(class I, level of evidence B)
0.5 mg by mouth daily 0.125 to 0.375 mg daily, orally
Amiodarone
(class IIb, level of evidence C)
800 mg daily for 1 week, orally
600 mg daily for 1 week, orally
400 mg daily for 4 to 6 week, orally
200 mg daily, orally

Pharmacological cardioversion

Pharmacological Cardioversion for Atrial Flutter
Drug Dosage
Flecainide
(class I, level of evidence A)
Oral: 200 to 300 mg
▸ Intravenous: 1.5 to 3.0 mg/kg, over 10 to 20 min
Ibutilide
(class I, level of evidence A)
Intravenous: 1 mg over 10 min, repeat 1 mg if necessary
Propafenone
(class I, level of evidence A)
Oral: 600 mg
▸ Intravenous: 1.5 to 2.0 mg/kg, over 10 to 20 min
Amiodarone
(class IIa, level of evidence A)
Oral:
Inpatient
1.2 to 1.8 g per day in divided dose until a maximum of 10 g
Followed by a maintenance dose of 200 to 400 mg per day or 30 mg/kg
Outpatient
600 to 800 mg per day divided dose until a maximum of 10 g
Followed by a maintenance dose of 200 to 400 mg per day

Intravenous:

5 to 7 mg/kg, over 30 to 60 min
Followed by 1.2 to 1.8 g per day continuous IV
OR
5 to 7 mg/kg, in divided oral doses until a maximum of 10 g
Followe by a maintenance dose of 200 to 400 mg per day

Antiarrhythmic Therapy

Maintenance of Sinus Rhythm
Amiodarone (100 to 400 mg)
OR
Disopyramide (400 to 750 mg)
OR
Dofetilide (500 to 1000 mcg)
OR
Flecainide (200 to 300 mg)
OR
Procainamide (1000 to 4000 mcg)
OR
Propafenone (450 to 900 mg)
OR
Quinidine (600 to 1500 mg)
OR
Sotalol (160 to 320 mg)

Anticoagulation Therapy

Shown below are tables depicting the assessment of risk of stroke and the appropriate anticoagulation therapy among patients with Atrial flutter.[4]

Anticoagulation Therapy
No risk factors Aspirin 81-325 mg daily
1 Moderate risk factor Aspirin 81-325 mg daily
OR
Warfarin (INR 2.0 to 3.0, target 2.5)
Any high risk factor or
more than 1 moderate risk factor
Warfarin (INR 2.0 to 3.0, target 2.5)


Risk Factors for Stroke
Low Risk Factors Moderate Risk Factors High Risk Factors
Female gender
Age 65-74 years
Coronary artery disease
Thyrotoxicosis
Age ≥ 75 years
Hypertension
Heart failure
LV ejection fraction ≤ 35%
Diabetes mellitus
Previous stroke, TIA or embolism
Mitral stenosis
Prosthetic heart valve

Do's

Don'ts

  • Do not use IV ibutilide in patients with structural cardiac diseases or prolonged QT interval or in those with sinus node disease.

References

  1. Gutierrez SD, Earing MG, Singh AK, Tweddell JS, Bartz PJ (2012). "Atrial Tachyarrhythmias and the Cox-maze Procedure in Congenital Heart Disease". Congenit Heart Dis. doi:10.1111/chd.12031. PMID 23280242. Unknown parameter |month= ignored (help)
  2. Granada, J.; Uribe, W.; Chyou, PH.; Maassen, K.; Vierkant, R.; Smith, PN.; Hayes, J.; Eaker, E.; Vidaillet, H. (2000). "Incidence and predictors of atrial flutter in the general population". J Am Coll Cardiol. 36 (7): 2242–6. PMID 11127467. Unknown parameter |month= ignored (help)
  3. "ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary". Retrieved 15 August 2013.
  4. 4.0 4.1 Fuster, V.; Rydén, LE.; Cannom, DS.; Crijns, HJ.; Curtis, AB.; Ellenbogen, KA.; Halperin, JL.; Kay, GN.; Le Huezey, JY. (2011). "2011 ACCF/AHA/HRS focused updates incorporated into the ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines". Circulation. 123 (10): e269–367. doi:10.1161/CIR.0b013e318214876d. PMID 21382897. Unknown parameter |month= ignored (help)

References


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