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Atrial Flutter

Atrial Flutters

Atrial flutter is a condition, characterized by abnormal heart rhythm that occurs in the atria of the heart. Such a type of condition is associated with a heart rate of 240 to 400 beats per minutes, a phenomenon known as tachycardia.


Presentation

Not every individual with atrial flutter will have symptoms. The reason is that healthy individuals can very well tolerate the increase in heart rate; however those with underlying disease conditions can experience pain in the chest, dyspnea, nausea, nervousness, and dizziness. In more severe cases, or when the flutter continues for longer duration, then it can lead to heart failure, or development of nocturnal breathlessness and edema of the legs and abdomen [6].

Patients suffering from atrial flutter have also reported to experience the following symptoms:

  • Anxiety
  • Tremor-like feeling in the heart accompanied by discomfort in the chest
  • Difficulty in carrying out everyday exercise or routine activities
  • Palpitations 
  • Fainting 
Fatigue
  • Cardiac arrhythmias also may cause light-headedness, fainting, chest pain, shortness of breath, fatigue or no symptoms at all.[hopkinsmedicine.org]
  • It produces feelings like near- fainting , rapid heartbeats ( palpitations ), mild shortness of breath , and fatigue . This type of arrhythmia can be dangerous because complications can easily develop.[medicinenet.com]
  • Some of them include: fast heart rate shortness of breath feeling lightheaded or faint pressure or tightness in the chest dizziness or lightheadedness heart palpitations trouble doing everyday activities because of fatigue Stress also raises your heart[healthline.com]
  • Signs and Symptoms Diagnosis Treatment Atrial flutter may cause the following symptoms: Chest pressure or pain Fainting, also known as syncope, or near-syncope Fatigue Lightheadedness or dizziness Palpitations, which can be skipping, fluttering or pounding[ucsfbenioffchildrens.org]
Chest Discomfort
  • Faster rates and variable AV conduction usually cause palpitations, and decreased cardiac output may cause symptoms of hemodynamic compromise (eg, chest discomfort, dyspnea, weakness, syncope).[merckmanuals.com]
  • However, many individuals with AF experience symptoms which may include palpitations, lightheadedness, near syncope, shortness of breath, fatigue, exercise intolerance, and chest discomfort (including chest pressure).[clinicaladvisor.com]
  • Symptoms may include a feeling of the heart beating too fast, too hard, or skipping beats, chest discomfort, difficulty breathing, a feeling as if one's stomach has dropped, a feeling of being light-headed, or loss of consciousness.[en.wikipedia.org]
  • discomfort (angina) because the heart is beating so fast that it is becoming ischemic.[teachingmedicine.com]
Dyspnea
  • Symptoms include palpitations and sometimes weakness, effort intolerance, dyspnea, and presyncope. Atrial thrombi may form and embolize. Diagnosis is by ECG.[merckmanuals.com]
  • The reason is that healthy individuals can very well tolerate the increase in heart rate; however those with underlying disease conditions can experience pain in the chest, dyspnea, nausea, nervousness, and dizziness.[symptoma.com]
  • Typical symptoms include the following: Palpitations Fatigue or poor exercise tolerance Mild dyspnea Presyncope Less common symptoms include angina, profound dyspnea, or syncope resulting from compromised left ventricular function.[emedicine.medscape.com]
  • Typical symptoms include the following: Palpitations Fatigue or poor exercise tolerance Mild dyspnea Presyncope Less common symptoms include angina, profound dyspnea, or syncope.[emedicine.com]
Aspiration
  • Intervention with thrombus aspiration and balloon dilatation was successful, and the patient recovered without any kind of sequelae.[ncbi.nlm.nih.gov]
Tachycardia
  • […] that was shown by fetal magnetocardiography to have transient AFl in addition to atrioventricular reciprocating tachycardia.[ncbi.nlm.nih.gov]
  • Abstract A 75-year-old man with a 120-bpm tachycardia and typical atrial flutter was admitted. Echocardiography showed a dilated left ventricle with anterior and apical wall akinesia. Tachycardia was terminated with cavotricuspid isthmus ablation.[ncbi.nlm.nih.gov]
  • Ventricular tachycardia must be the first consideration in patients with regular wide complex tachycardia.[ncbi.nlm.nih.gov]
  • Abstract We report the case of a 67-year-old female with a wide QRS complex tachycardia at 180 bpm. A diagnosis of class IC atrial flutter with aberrant ventricular conduction caused by flecainide therapy was formulated.[ncbi.nlm.nih.gov]
  • This case demonstrated that PV carina tachycardia with multiple conduction gaps and inter-PV conduction after PVI might mimic double focal atrial tachycardias. 2013 Wiley Periodicals, Inc.[ncbi.nlm.nih.gov]
Heart Disease
  • Two main groups were considered: No PCS and PCS patients, who were further subdivided into acquired heart disease (AHD: ischaemic heart disease and valvular/mixed heart disease) and congenital heart disease [CHD: ostium secundum atrial septal defect ([ncbi.nlm.nih.gov]
  • A history of heart disease, anxiety issues, and high blood pressure can all affect your risk. Your primary care doctor can diagnose AFL. You may also be referred to a cardiologist for testing.[healthline.com]
  • Cause: Underlying heart disease, stress, anxiety and open heart surgery, predisposes an individual to develop atrial flutter.[symptoma.com]
  • disease Congenital heart disease Atrial flutter often presents at a rate of 150 bpm on admission.[nottingham.ac.uk]
  • Atrial flutter is relatively uncommon and is most often seen in patients presenting with acute ischemic heart disease or pulmonary embolism. Nevertheless, it can present as a chronic condition in patients who suffer from organic heart disease.[meds.queensu.ca]
Palpitations
  • Abstract A 46-year-old man was admitted to our hospital for near syncope and palpitations. An electrocardiogram showed a common type of atrial flutter (AFL) with 1:1 atrioventricular conduction.[ncbi.nlm.nih.gov]
  • At hospital admission she reported no family history of sudden cardiac death, nor syncope or paroxysmal palpitations. The cardiac echocardiographical exam revealed no structural abnormalities and a normal ejection fraction.[ncbi.nlm.nih.gov]
  • Three years later he again suffered palpitations and atypical atrial flutter was documented. The electrophysiology study confirmed the diagnosis of atypical left flutter and reappearance of electrical activity in the right inferior pulmonary vein.[ncbi.nlm.nih.gov]
  • Symptoms depend on how fast the ventricles contract and may include palpitations, weakness, dizziness or light-headedness, shortness of breath, and chest pain. Electrocardiography (ECG) confirms the diagnosis.[msdmanuals.com]
  • We report an adverse event associated with adenosine administered for diagnostic purposes to a patient with atrial flutter.A 53-year-old man came for medical evaluation because of palpitations.[nejm.org]
Chest Pain
  • After the procedure, the chest pain was getting worse, and the electrocardiogram showed ST-segment elevation in inferior leads with reciprocal changes.[ncbi.nlm.nih.gov]
  • Six weeks after his second procedure, while performing intense sprint intervals on a treadmill, he developed an abrupt onset of chest pain, hypotension, and cardiac tamponade.[ncbi.nlm.nih.gov]
  • Symptoms depend on how fast the ventricles contract and may include palpitations, weakness, dizziness or light-headedness, shortness of breath, and chest pain. Electrocardiography (ECG) confirms the diagnosis.[msdmanuals.com]
  • ., diltiazem ) if the affected person is not having chest pain, has not lost consciousness, and if their blood pressure is normal (known as stable atrial flutter).[en.wikipedia.org]
  • Symptoms of Atrial Flutter and AFib These symptoms include the following: Palpitations (a fluttering, fast heartbeat) Weakness or tiredness Shortness of breath Chest pain or tightness Dizziness or lightheadedness Fainting spells[saintlukeshealthsystem.org]
Hypotension
  • Immediately post-cardioversion, he suffered severe hypotension with a depressed LV systolic function. IV dobutamine stabilized his blood pressure. Copyright 2013 Elsevier Inc. All rights reserved.[ncbi.nlm.nih.gov]
  • Six weeks after his second procedure, while performing intense sprint intervals on a treadmill, he developed an abrupt onset of chest pain, hypotension, and cardiac tamponade.[ncbi.nlm.nih.gov]
  • Loading dose of landiolol hydrochloride 7.5 mg followed by 1.5-3 μg/kg/min continuous administration was given, which had decreased the conduction ratio to 2:1 without causing hypotension.[ncbi.nlm.nih.gov]
  • Synchronized electrical cardioversion is often used if: hypotensive, ischemic pain or severe CHF are present Type I antiarrhythmics like quinidine or procainamide may convert the flutter Diltiazem, verapamil, digitalis or beta-blocking agents may be used[rnceus.com]
  • These patients would be complaining of pain, have a heart rate over 150, shortness of breath, altered levels of consciousness or hypotension. The patient should be treated with an IV sedative prior to cardioversion if time permits.[mstcparamedic.pbworks.com]
Stroke
  • After adjustment for demographics and stroke risk factors, flutter was associated with a lower risk of stroke compared with fibrillation (hazard ratio .69; 95% CI .60-.79, P CONCLUSIONS: Patients with atrial flutter faced a lower risk of ischemic stroke[ncbi.nlm.nih.gov]
  • The clinical end point was occurrence of ischemic stroke during follow-up after AFL ablation.[ncbi.nlm.nih.gov]
  • Given the difficulties in detecting AF and the uncertainty about the temporal relation of AF and stroke, oral anticoagulation may need to be continued in those patients with underlying stroke risk factors. 2016 Wiley Periodicals, Inc.[ncbi.nlm.nih.gov]
  • The secondary outcome was the occurrence of stroke or transient ischemic attack (TIA) in follow-up. The statistical significance level was 5%.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: The clinical effects of digoxin on all-cause mortality, serious adverse events, quality of life, heart failure, and stroke are unclear based on current evidence.[ncbi.nlm.nih.gov]
Dizziness
  • The reason is that healthy individuals can very well tolerate the increase in heart rate; however those with underlying disease conditions can experience pain in the chest, dyspnea, nausea, nervousness, and dizziness.[symptoma.com]
  • This can cause you to feel dizzy or weak. Blood that doesn’t keep moving can pool and form clots in the atria. These clots can move into other parts of the body and cause serious problems such as a stroke.[saintlukeshealthsystem.org]
  • Symptoms depend on how fast the ventricles contract and may include palpitations, weakness, dizziness or light-headedness, shortness of breath, and chest pain. Electrocardiography (ECG) confirms the diagnosis.[msdmanuals.com]
  • Atrial flutter is less common than atrial fibrillation Atrial flutter is less common, but has similar symptoms (feeling faint, tiredness, palpitations, shortness of breath or dizziness). Some people have mild symptoms, others have none at all.[bhf.org.uk]
Akinesia
  • Echocardiography showed a dilated left ventricle with anterior and apical wall akinesia. Tachycardia was terminated with cavotricuspid isthmus ablation.[ncbi.nlm.nih.gov]
Quadriplegia
  • We report a case of pseudo-atrial flutter in a 67-year-old male with quadriplegia and ventilator dependence due to amyotrophic lateral sclerosis (ALS) who was hospitalized for respite care.[ncbi.nlm.nih.gov]

Workup

A preliminary physical examination will be done, followed by the following diagnostic procedures:

  • Electrocardiogram [7] 
  • Holter monitor: This is a device for continuous recording of the heart beat for 24 to 72 hours.
  • Echocardiogram: This is done to evaluate the shape, size as well as motion of the heart. In addition, transthoracic echocardiography is also a preferred mode for evaluating atrial flutter.
  • Electrophysiological study: This would help in identifying the exact location of the abnormal rhythm. Such a type of method would also help in treating the condition.
Narrow QRS Complex
  • To the Editor: Adenosine is the treatment of choice for tachycardia with narrow QRS complexes involving the atrioventricular node as part of its reentrant circuit 1 .[nejm.org]
  • Since flutter waves tend to be somewhat wide and rarely fall perfectly inside a narrow QRS complex, you can often find signs of buried waves as slurring in the upstroke or downstroke of the QRS.[ems12lead.com]
Toxoplasma Gondii
  • We report a confirmed case of congenital toxoplasmosis identified because of atrial flutter in the fetus and linked to maternal consumption of Toxoplasma gondii PCR-positive moose meat.[ncbi.nlm.nih.gov]

Treatment

The basic objective of treatment is to reduce the electrical impulses, which would in turn help in normalizing the heart beat. In order to achieve this, the following methods would be employed [8]:

  • Medications: Various medications such as beta blockers, adenosine, digoxin and calcium channel antagonists, are administered for treating atrial flutter. In addition, antiarrhythmics would also be required, to treat the condition. These include propafenone, amiodarone, ibutilide, sotalol, flecainide and dofetilide.
  • Debrillation: In this method, defibrillation is applied externally, to bring back the heart beat to normal. This method is also known as cardioversion [9].
  • Ablation therapy: This is the treatment of choice, and is employed when medications do not work, and individuals experience repeated bouts of atrial flutter. Such a therapy is carried out during the electrophysiological study; wherein the area from where abnormal heart rhythm arises is destroyed with the help of the same catheters [10].
  • Anticoagulation: This is important for preventing recurrent bouts of atrial flutter and also help onset of complications from setting in.

Prognosis

When appropriately treated, atrial flutter can be successfully managed, and seldom gives rise to any complications. However, without treatment, it can lead to development of stroke and blood clots [5]. Underlying medical conditions gravely affect the prognosis of atrial flutter. Patients with Wolff-Parkinson-White syndrome, who also suffer from atrial flutter, are at risk of developing life threatening consequences, if catheter ablation is not considered in such cases. Also, untreated atrial flutter can lead to atrial fibrillation, cardiomyopathy and long term disability.

Etiology

Individuals living with heart disease, or those who have undergone open heart surgery, are at an increased risk of developing atrial flutter. Stress and anxiety can also considerably increase the risk of the condition. Certain medications prescribed for cold, overuse of caffeine, diet pills and alcohol, predispose an individual to develop atrial flutter [2].

In addition to the above mentioned conditions, there are various risk factors that significantly increase the chances of atrial flutter. These include:

Epidemiology

The condition of atrial flutter majorly affects the population of older adults. About 200,000 new cases of atrial flutter are known to occur in the US every year [3]. Men are at an increased risk of developing the condition. In a study of 100 patients suffering from atrial flutter, it was seen that 75% of them were males.

Sex distribution
Age distribution

Pathophysiology

Factors that interfere with the appropriate functioning of the electrical impulses of the heart, may give rise to the condition of atrial flutter. Under normal conditions, the sinus node controls the heart, which is situated on the top of the atrium. In this condition, the atria send out reentrant rhythms that overwhelm the sinus node. Such a phenomenon causes the atria to contract rapidly [4].

Prevention

The following steps can be taken for preventing attacks of atrial flutter:

  • Decrease the consumption of caffeine, alcohol, nicotine and stimulants.
  • Prompt treatment for underlying heart ailments.
  • Significantly decrease the stress and anxiety levels.

Summary

This condition was described and identified as an independent medical condition by British physician Sir Thomas Lewis in the year 1920. Atrial flutter is grouped into the category of supraventricular tachycardia. In this condition, the atria of heart beat so fast, that the muscle contractions of the atria are faster than those of ventricles. Atrial flutter is associated with certain degree of atrioventricular node conduction block [1].

Patient Information

  • Definition: Atrial flutter is characterized by abnormal heart rhythms, which arise from the atrial chamber of the heart. It is a rare condition as compared to atrial fibrillation. Males are at an increased risk of contracting this condition than females.
  • Cause: Underlying heart disease, stress, anxiety and open heart surgery, predisposes an individual to develop atrial flutter. In addition, caffeine, stimulants, nicotine, alcohol and smoking, also considerably increase the chances of developing atrial flutter.
  • Symptoms: Symptoms of atrial flutter include fast paced heart beat, dizziness, lightheadedness, anxiety, shortness of breath and discomfort in the chest. Individuals also complain of tremor-like feeling in the heart.
  • Diagnosis: Atrial flutter is diagnosed using the electrocardiogram, echocardiogram, holter monitor and electrophysiological study.
  • Treatment: The major goal of treating atrial flutter includes bringing back the abnormal heart beat to normal, and prevention of future attacks. Medications, cardioversion, ablation therapy, and blood thinners are employed for treating attacks of atrial flutter.

References

Article

  1. Garson A Jr, Bink-Boelkens M, Hesslein PS, et al. Atrial flutter in the young: a collaborative study of 380 cases. J Am Coll Cardiol 1985; 6:871.
  2. Ghali WA, Wasil BI, Brant R, Exner DV, Cornuz J. Atrial flutter and the risk of thromboembolism: a systematic review and meta-analysis. Am J Med. Feb 2005;118(2):101-7.
  3. Granada J, Uribe W, Chyou PH, et al. Incidence and predictors of atrial flutter in the general population. J Am Coll Cardiol 2000; 36:2242.
  4. Olesen MS, Holst AG, Jabbari J, Nielsen JB, Christophersen IE, Sajadieh A, et al. Genetic loci on chromosomes 4q25, 7p31, and 12p12 are associated with onset of lone atrial fibrillation before the age of 40 years. Can J Cardiol. Mar-Apr 2012;28(2):191-5
  5. Biblo LA, Yuan Z, Quan KJ, Mackall JA, Rimm AA. Risk of stroke in patients with atrial flutter. Am J Cardiol. Feb 1 2001;87(3):346-9, A9
  6. Alboni P, Scarfò S, Fucà G, et al. Atrial and ventricular pressures in atrial flutter. Pacing Clin Electrophysiol 1999; 22:600.
  7. FOSMOE RJ, AVERILL KH, LAMB LE. Electrocardiographic findings in 67,375 asymptomatic subjects. II. Supraventricular arrhythmias. Am J Cardiol 1960; 6:84.
  8. Wellens HJ. Contemporary management of atrial flutter. Circulation 2002; 106:649.
  9. Crijns HJ, Van Gelder IC, Tieleman RG, et al. Long-term outcome of electrical cardioversion in patients with chronic atrial flutter. Heart 1997; 77:56.
  10. Coffey JO, d'Avila A, Dukkipati S, Danik SB, Gangireddy SR, Koruth JS, et al. Catheter ablation of scar-related atypical atrial flutter. Europace. Mar 2013;15(3):414-9.

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Last updated: 2018-06-22 10:50