Question

    Atrial Flutter (Atrial Flutters)

    Atrial flutter34[1]

    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.

    Atrial Flutter stems from this process: endocrine.

    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 

    Entire body system
    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]
    • Higher rates cause unpleasant awareness of heart beats ( palpitations ) or chest discomfort.[merckmanuals.com]
    Fatigue
    • Palpitations Fatigue or poor exercise tolerance Mild dyspnea Presyncope[emedicine.medscape.com]
    • Blood clots can form in the heart, legs, arteries, veins, bladder, urinary tract and Fatigue Fatigue can be described in various ways.[medicinenet.com]
    • Cardiac arrhythmias also may cause light-headedness, fainting, chest pain, shortness of breath, fatigue or no symptoms at all.[hopkinsmedicine.org]
    • It can lead to symptoms of palpitations, shortness of breath, fatigue, or lightheadedness, as well as an increased risk of atrial thrombus formation that may cause cerebral and/or systemic embolization.[uptodate.com]
    • […] alcohol, and quitting smoking if you are a smoker will help. 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[healthline.com]
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  • neurologic
    Dizziness
    • Symptoms: Symptoms of atrial flutter include fast paced heart beat, dizziness, lightheadedness, anxiety, shortness of breath and discomfort in the chest.[symptoma.com]
    • There are lifestyle changes Dizziness Dizziness is a symptom that is often applies to a variety of sensations including lightheadedness and vertigo.[medicinenet.com]
    • This can cause problems including dizziness , shortness of breath and tiredness.[nhs.uk]
    • […] healthy lifestyle with a well-balanced diet and regular exercise, refraining from too much alcohol, and quitting smoking if you are a smoker will help. fast heart rate shortness of breath feeling lightheaded or faint pressure or tightness in the chest dizziness[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]
    Vertigo
    • There are lifestyle changes Dizziness Dizziness is a symptom that is often applies to a variety of sensations including lightheadedness and vertigo.[medicinenet.com]
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  • respiratoric
    Dyspnea
    • Palpitations Fatigue or poor exercise tolerance Mild dyspnea Presyncope[emedicine.medscape.com]
    • Symptoms include palpitations and sometimes weakness, effort intolerance, dyspnea, and presyncope.[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]
    • Other symptoms include fatigue, dyspnea, and chest pain.[emedicine.medscape.com]
    • Galloping heart Exercise intolerance Weakness Cough Dyspnea (Difficult breathing) Tachypnea (Rapid respiratory rate ) Lethargy Syncope/Loss of consciousness (rare) Causes Chronic disease of the heart involving the valves Enlargement of the heart Cardiomyopathy[petmd.com]
    Exertional Dyspnea
    • The most encountered signs are fatigue, exertional dyspnea and general discomfort.[fac.org.ar]
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  • cardiovascular
    Chest Pain
    • PSVT was referred to at one time Chest Pain Chest pain is a common complaint by a patient in the ER.[medicinenet.com]
    • Cardiac arrhythmias also may cause light-headedness, fainting, chest pain, shortness of breath, fatigue or no symptoms at all.[hopkinsmedicine.org]
    • These include: Heart palpitations Fast pulse Chest pain Lightheadedness and fainting Treatment Treatment for atrial flutter is similar to atrial fibrillation.[lifebridgehealth.org]
    • pain Cardiac Echo - if signs of new/worsening heart failure Flutter with alternating 2:1 and 3:1 block.[wikem.org]
    Heart Disease
    • Cause: Underlying heart disease, stress, anxiety and open heart surgery, predisposes an individual to develop atrial flutter.[symptoma.com]
    • Heart disease is a major cause of AFL.[healthline.com]
    • Health Centers Heart Disease Heart disease is the biggest health risk Americans face today.[sw.org]
    • In dogs with AF secondary to structural heart disease , Digoxin is usually the first line of therapy.[en.wikivet.net]
    • With an arrhythmia, the heartbeats may be irregular or too slow (bradycardia), to rapid (tachycardia), or too Stress and Heart Disease The connection between stress and heart disease is not clear.[medicinenet.com]
    Irregular Heart Rhythm
    • Atypical Aflutter may have varying AV conduction, which can cause an irregular heart rhythm.[ecg-quiz.com]
    • Both are irregular heart rhythms (arrhythmias) caused by an electrical problem in the heart.[baptistgoodforyou.com]
    • Findings on clinical examination will include an irregularly irregular heart rhythm on auscultation with no fourth heart sound.[en.wikivet.net]
    Palpitations
    • Symptoms can include increased heart rate, Palpitations Palpitations are uncomfortable sensations of the heart beating hard, rapidly, or irregularly.[medicinenet.com]
    • Palpitations Fatigue or poor exercise tolerance Mild dyspnea Presyncope[emedicine.medscape.com]
    • Symptoms include palpitations and sometimes weakness, effort intolerance, dyspnea, and presyncope.[merckmanuals.com]
    • They are common and may cause a wide variety of symptoms, such as a racing, skipping or fluttering sensation (called palpitations) in your chest.[hopkinsmedicine.org]
    • It can lead to symptoms of palpitations, shortness of breath, fatigue, or lightheadedness, as well as an increased risk of atrial thrombus formation that may cause cerebral and/or systemic embolization.[uptodate.com]
    Tachycardia
    • There are three major types of SVT including: Atrial fibrillation Paroxysmal supraventricular tachycardia (PSVT) Atrial Flutter & Atrial Tachycardia Atrial Flutter & Atrial Tachycardia Typical atrial flutter results from a single "short-circuit" in the[hopkinsmedicine.org]
    • AFL manifests with tachycardia and congestive heart failure.[orpha.net]
    • Although they are supraventricular in origin, apart from atrial tachycardia, they are not generally included in the nomenclature of supraventricular tachycardia.[intechopen.com]
    • C haracterisation of reentrant circuits in left atrial macroreentrant tachycardia: critical isthmus block can prevent atrial tachycardia recurrence .[escardio.org]
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  • 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.

    ECG

    Other ECG Findings
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  • 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.

    Complications

    Angina Pectoris
    • pectoris (chest or heart pains) Feeling faint or light-headed Fainting (syncope) When to Seek Medical Care for Atrial Flutter If you experience any of the symptoms of atrial flutter, call your health care provider for an appointment.[webmd.com]
    Atrial Fibrillation
    • Atrial Fibrillation or Atrial Flutter St.[centerwatch.com]
    • So a patient will have a brief burst of atrial fibrillation.[abcnews.go.com]
    • Medical Therapy for Atrial Fibrillation & Atrial Flutter in Adults Our cardiologists may use medication to help manage atrial fibrillation and atrial flutter.[nyulangone.org]
    Atrial Flutter
    Cardiac Arrhythmia
    • […] disorders with mcc 309 Cardiac arrhythmia and conduction disorders with cc 310 Cardiac arrhythmia and conduction disorders without cc/mcc 793 Full term neonate with major problems Convert ICD-10-CM I48.92 to ICD-9-CM The following ICD-10-CM Index entries[icd10data.com]
    • . flutter [ flut er ] a rapid vibration or pulsation. atrial flutter a cardiac arrhythmia in which the atrial contractions are rapid (230–380 per minute), but regular.[medical-dictionary.thefreedictionary.com]
    • Cardiac arrhythmias also may cause light-headedness, fainting, chest pain, shortness of breath, fatigue or no symptoms at all.[hopkinsmedicine.org]
    • Cardiology Teaching Package A Beginners Guide to Normal Heart Function, Sinus Rhythm & Common Cardiac Arrhythmias Atrial Flutter There are many similarities between atrial fibrillation and atrial flutter, there are also significant differences.Atrial[nottingham.ac.uk]
    • Medications, pacing through the catheters and the recording of the heart’s electrical signals help doctors identify cardiac arrhythmias.[scripps.org]
    Hypotension
    • 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]
    • Severe hypotension and death may ensue if the cardiac rhythm is not carefully tracked.[emedicine.medscape.com]
    • If hypotension is present from a significantly reduced cardiac output, dizziness and even syncope (loss of consciousness) can occur.[healio.com]
    • There are some severe side effects which can occur with this treatment and they include ventricular tachycardia , colic , diarrhoea and hypotension.[en.wikivet.net]
    • […] given to anticoagulation prior to cardioversion in longer cases [9] Evidence of preexcitation Avoid AV nodal agents Unstable: Unsynchronized cardioversion (200J) Procainamide (if cardioversion unsuccessful) 20-50mg/min until arrhythmia is controlled, hypotension[wikem.org]
    Paroxysmal Atrial Fibrillation
    • Seven patients (5%) had a history of thromboembolism, all of whom also had paroxysmal atrial fibrillation.[content.onlinejacc.org]
    • For example: paroxysmal atrial fibrillation – episodes come and go, and usually stop within 48 hours without any treatment persistent atrial fibrillation – each episode lasts for longer than seven days (or less when it's treated) long-standing persistent[nhs.uk]
    • Types Atrial fibrillation is categorized by relevance, including: Primary atrial fibrillation No underlying cardiac disease involved – cause not identified Secondary atrial fibrillation Severe underlying cardiac disease like CHF is usually involved Paroxysmal[petmd.com]
    • Wilber DJ , Pappone C , Neuzil P, De Paola A, Marchlinski F, et al. (2010) Comparison of antiarrhythmic drug therapy and radiofrequency catheter ablation in patients with paroxysmal atrial fibrillation: a randomized controlled trial.[esciencecentral.org]
    Stroke
    • Reducing the Risk of Stroke Some patients with atrial flutter may be at an increased risk of stroke if certain other risk factors are present.[circ.ahajournals.org]
    • Atrial fibrillation was not found to be an independent risk factor for stroke in chronic atrial flutter in a recent retrospective study suggesting that atrial flutter alone conferred some risk of thromboembolic stroke (14) .[content.onlinejacc.org]
    • As with atrial fibrillation, the decision to start warfarin or other stroke-preventing medication is based on an individual's overall stroke risk.[sharecare.com]
    • The risk of stroke is not the same for all people with atrial flutter .[washingtonhra.com]
    Supraventricular Tachycardia
    • Supraventricular tachycardia is a series of rapid heartbeats that begin in or involve the upper chambers (atria) of the heart.[hopkinsmedicine.org]
    • Heart flutter can’t always be detected separate from other types of supraventricular tachycardia such as atrial fibrillation by an electrocardiogram or a heart monitor alone.[scripps.org]
    • Differential diagnosis Differential diagnosis includes multifocal atrial tachycardia (see this term) and other forms of supraventricular tachycardia.[orpha.net]
    • Tachycardia (PSVT) Paroxysmal supraventricular tachycardia (PSVT) is an abnormal conduction of electricity in particular areas of the heart.[medicinenet.com]
    • Background Supraventricular Tachycardia Atrial re-entry circuit Defined by atrial rate of 250-350, classically 300 Clinical Features Asymptomatic Palpitations Fatigue Dyspnea Pre-syncope/ syncope Differential Diagnosis Can be difficult to distinguish[wikem.org]
    Syncope
    • Typical symptoms include the following: Less common symptoms include angina, profound dyspnea, or syncope resulting from compromised left ventricular function.[emedicine.medscape.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]
    • Background Supraventricular Tachycardia Atrial re-entry circuit Defined by atrial rate of 250-350, classically 300 Clinical Features Asymptomatic Palpitations Fatigue Dyspnea Pre-syncope/ syncope Differential Diagnosis Can be difficult to distinguish[wikem.org]
    • For the most part, morbidity and mortality are due to complications of rate (eg, syncope and congestive heart failure [CHF]).[emedicine.medscape.com]
    • Galloping heart Exercise intolerance Weakness Cough Dyspnea (Difficult breathing) Tachypnea (Rapid respiratory rate ) Lethargy Syncope/Loss of consciousness (rare) Causes Chronic disease of the heart involving the valves Enlargement of the heart Cardiomyopathy[petmd.com]
    Thromboembolism
    • Seven patients (5%) had a history of thromboembolism, all of whom also had paroxysmal atrial fibrillation.[content.onlinejacc.org]
    • Treatment Rate control with drugs Rhythm control with cardioversion, drugs, or ablation Prevention of thromboembolism Treatment focuses on ventricular rate control, rhythm control, and prevention of thromboembolism.[merckmanuals.com]
    • Thromboembolism with transient ischaemic attacks or stroke.[patient.info]
    • Thromboembolic events are possible with this arrhythmia.[emedicine.medscape.com]
    • Time to cardioversion for acute atrial fibrillation and thromboembolic complications.[wikem.org]
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  • 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.

    Self-assessment

    References

    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.

    • Atrio-esophageal fistula as a complication of percutaneous transcatheter ablation of atrial fibrillation - C Pappone, H Oral, V Santinelli, G Vicedomini - Circulation, 2004 - Am Heart Assoc
    • Assess the efficacy of dronedarone 400 mg BID for the prevention of cardiovascular hospitalization or death from any cause in patients with atrial fibrillation/atrial flutter - SJ Connolly, HJGM Crijns, C Torp-Pedersen - Circulation, 2009 - Am Heart Assoc
    • Cardiac involvement in Cooley's anemia - MA Engle - Annals of the New York Academy of Sciences, 2006 - Wiley Online Library
    • Acute cavitary histoplasmosis. - SF Davies, GA Sarosi - CHEST Journal, 1978 - journal.publications.chestnet.org
    • In converting to and maintaining sinus rhythm in patients with chronic atrial fibrillation or atrial flutter: the symptomatic atrial fibrillation investigative research on - S Singh, RG Zoble, L Yellen, MA Brodsky, GK Feld - Circulation, 2000 - Am Heart Assoc
    • Diagnostic approach to palpitations - AV Abbott - American Family Physician, 2005 - cardiophonics.com
    • Cryoablation of Supraventricular Tachycardia (Atrial Fibrillation, Atrial Flutter, Wolff‐Parkinson‐White Syndrome, Atrioventricular Nodal Reentry Tachycardia) - LUZ RODRIGUEZ, JC Geller, HFAT TSE - Journal of , 2003 - Wiley Online Library
    • Ablation ofIncisional'Reentrant Atrial Tachycardia Complicating Surgery for Congenital Heart Disease: Use of Entrainment to Define a Critical Isthmus of Conduction - JM Kalman, GF VanHare, JE Olgin, LA Saxon, SI Stark - Circulation, 1996 - Am Heart Assoc
    • Cryoablation of Supraventricular Tachycardia (Atrial Fibrillation, Atrial Flutter, Wolff‐Parkinson‐White Syndrome, Atrioventricular Nodal Reentry Tachycardia) - LUZ RODRIGUEZ, JC Geller, HFAT TSE - Journal of , 2003 - Wiley Online Library
    • Acute effects of dual-site right atrial pacing in patients with spontaneous and inducible atrial flutter and fibrillation - A Prakash, S Saksena, M Hill, RB Krol - Journal of the , 1997 - Am Coll Cardio Found
    • And clinical predictors of torsades de pointes induced by almokalant infusion in patients with chronic atrial fibrillation or flutter: a prospective study - B Houltz, B DARPÖ, N Edvardsson - Pacing and clinical , 2006 - Wiley Online Library

    Media References

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