Atrial flutter - Revision history

Danbot: Add MedicationDose SMW entries for diltiazem, amiodarone, procainamide; doses verified against AHA ACLS guidelines

2026-03-20T18:01:28Z

Add MedicationDose SMW entries for diltiazem, amiodarone, procainamide; doses verified against AHA ACLS guidelines

← Older revision		Revision as of 18:01, 20 March 2026
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	*Stable:		*Stable:
	**Try to avoid [[cardioversion]] without adequate anticoagulation		**Try to avoid [[cardioversion]] without adequate anticoagulation


			==Medication Dosing==
			===Rate Control===
			*{{MedicationDose\|drug=Diltiazem\|dose=2.5 mg/min until HR <100 (max 50 mg)\|route=IV\|context=Rate control\|indication=Atrial flutter\|population=Adult}}
			*{{MedicationDose\|drug=Amiodarone\|dose=150 mg over 10 min\|route=IV\|context=Rate control (alternative)\|indication=Atrial flutter\|population=Adult\|notes=Preferably via central venous access}}

			===Preexcitation===
			*{{MedicationDose\|drug=Procainamide\|dose=20-50 mg/min until arrhythmia controlled\|route=IV\|context=Preexcited atrial flutter\|indication=Atrial flutter\|population=Adult\|max_dose=17 mg/kg\|notes=Stop if hypotension or QRS widens >50%}}

	==Disposition==		==Disposition==

Rossdonaldson1: /* Evaluation */

2025-07-30T17:06:59Z

Evaluation

← Older revision		Revision as of 17:06, 30 July 2025
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	==Evaluation==		==Evaluation==
			[[File:Aflutter.jpg\|thumb\|Flutter with alternating 2:1 and 3:1 block.]]
			[[File:Atrial flutter.jpg\|thumb\|Atrial flutter with variable block]]
	*[[ECG]]		*[[ECG]]
	*CBC		*CBC
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	*[[Ultrasound:_Cardiac\|Cardiac Echo]] - if signs of new/worsening heart failure		*[[Ultrasound:_Cardiac\|Cardiac Echo]] - if signs of new/worsening heart failure

	~~[[File:Aflutter.jpg\|thumb\|Flutter with alternating 2:1 and 3:1 block.]]~~
	~~[[File:Atrial flutter.jpg\|thumb\|Atrial flutter with variable block]]~~
	===[[ECG]]===		===[[ECG]]===
	*Narrow complex tachycardia		*Narrow complex tachycardia
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	**Does not meet criteria for typical atrial flutter		**Does not meet criteria for typical atrial flutter
	**Less amenable to treatment		**Less amenable to treatment


	==Management==		==Management==

Patricklin at 04:28, 17 March 2024

2024-03-17T04:28:38Z

← Older revision		Revision as of 04:28, 17 March 2024
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	==Background==		==Background==
	*[[~~Supraventricular Tachycardia~~]]		*A form of [[supraventricular tachycardia]] that is caused by a re-entry circuit, typically within the right atrium
	**Atrial re-entry circuit		**Second most common arrhythmia, after [[atrial fibrillation]]
	*Defined by atrial rate of 250-350, classically 300		*Defined by atrial rate of 250-350, classically 300
			*Associated with underlying diseases that cause atrial remodeling/dilation, such as [[hypertension]], [[chronic obstructive pulmonary disease]], [[heart failure]], [[pulmonary hypertension]]
			**Acutely, may be precipitated by antiarrhythmic medications, [[acute coronary syndrome]], or cardiac surgery/procedures

	==Clinical Features==		==Clinical Features==
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	*[[Dyspnea]]		*[[Dyspnea]]
	*Pre-syncope/[[syncope]]		*Pre-syncope/[[syncope]]
			*[[Hypotension]]

	==Differential Diagnosis==		==Differential Diagnosis==
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	*Narrow complex tachycardia		*Narrow complex tachycardia
	**Usually regular unless variable AV conduction present		**Usually regular unless variable AV conduction present
	*~~Atrial rate near 300~~		**Usually narrow unless aberrancy present
	*~~Flutter~~ waves (sawtooth pattern) in inferior leads		*Typical P waves are absent, but flutter waves (sawtooth pattern) are found in inferior leads
	**Hallmark is discordance in flutter wave direction between inferior leads and V1		**Hallmark is discordance in flutter wave direction between inferior leads and V1; see below for specific types
	*AV nodal ~~conduction~~		*Atrial rate near 300, appearing as flutter waves at 300 bpm
			*Ventricular rate = 300 divided by the conduction ratio
			**2:1 block = 150 bpm
			**3:1 block = 100 bpm, and so on
			*Conduction ratio depends on sympathetic/parasympathetic balance, AV node refractoriness, AV node disease, AV nodal blockers
	**1:1 conduction can be unstable		**1:1 conduction can be unstable
	***Suggests pre-excitation, sympathetic excess, parasympathetic withdrawal, Class 1C anti-arrhythmic use		***Suggests pre-excitation, sympathetic excess, parasympathetic withdrawal, Class 1C anti-arrhythmic use
			***Less common since AV node refractory period prevents 1:1 conduction
	**2:1 conduction is most common		**2:1 conduction is most common
	***Suspect atrial flutter whenever ventricular rate is 150		***Suspect atrial flutter whenever ventricular rate is approximately 150
	**~~conduction~~ >2:1		***Note flutter waves may be mistaken for P and T waves
			**Conduction >2:1
	***More commonly even ratio		***More commonly even ratio
	***Suggests AV nodal blocking agents or AV node disease		***Suggests AV nodal blocking agents or AV node disease
	**Variable block		**Variable block
	***Difficult to distinguish from [[atrial fibrillation]]		***Difficult to distinguish from [[atrial fibrillation]]
	***Look for: R-R interval that is multiple of P-P interval and mathematical relationship between R-R intervals		***Look for: R-R interval that is multiple of P-P interval and mathematical relationship between R-R intervals (alternating between 2:1, 3:1, 4:1, etc)
	***A-fib is completely irregular with no relationship between intervals		***A-fib is completely irregular with no relationship between intervals
	*Amal Mattu recommends flipping ECG 180 to easily see inverted P waves or speed machine up to 50 mm/s to stretch out ECG		*Amal Mattu recommends flipping ECG 180 to easily see inverted P waves or speed machine up to 50 mm/s to stretch out ECG
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	===Types===		===Types===
	*Type 1 (Typical Atrial Flutter)		*Type 1 (Typical Atrial Flutter)
	**Re-entry circuit of right atrium ~~(IVC and tricuspid valve)~~		**Re-entry circuit of the cavotricuspid-isthmus (CTI) pathway in the right atrium
	***Anticlockwise circuit- 90% of cases		***Anticlockwise circuit- 90% of cases
	****Inverted flutter waves in inferior leads		****Inverted flutter waves in inferior leads
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	****Inverted flutter waves in V1		****Inverted flutter waves in V1
	*Type 2 (Atypical Atrial Flutter)		*Type 2 (Atypical Atrial Flutter)
			**Not associated with the CTI pathway, but may be due to arrhythmogenic scars from prior atrial instrumentation
	**Does not meet criteria for typical atrial flutter		**Does not meet criteria for typical atrial flutter
	**Less amenable to treatment		**Less amenable to treatment


	==Management==		==Management==

Dieseldoc: /* ECG */

2021-10-06T00:56:07Z

ECG

← Older revision		Revision as of 00:56, 6 October 2021
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	*Atrial rate near 300		*Atrial rate near 300
	*Flutter waves (sawtooth pattern) in inferior leads		*Flutter waves (sawtooth pattern) in inferior leads
			**Hallmark is discordance in flutter wave direction between inferior leads and V1
	*AV nodal conduction		*AV nodal conduction
	**1:1 conduction can be unstable		**1:1 conduction can be unstable

Blsimpso: /* External Links */

2021-09-25T12:43:02Z

External Links

← Older revision		Revision as of 12:43, 25 September 2021
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	==External Links==		==External Links==
	*[https://emcrit.org/ibcc/af/ IBCC - Atrial Fibrillation and Flutter complicating critical illness]		*[https://emcrit.org/ibcc/af/ IBCC - Atrial Fibrillation and Flutter complicating critical illness]
			*[http://www.emdocs.net/em3am-atrial-flutter/ emDOCS - Atrial Flutter]
			*[https://www.merckmanuals.com/professional/cardiovascular-disorders/arrhythmias-and-conduction-disorders/atrial-flutter Merck Manual - Atrial Flutter]

	==References==		==References==

Blsimpso: /* Disposition */

2021-09-25T12:40:35Z

Disposition

← Older revision		Revision as of 12:40, 25 September 2021
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	==Disposition==		==Disposition==
			===Admission===
			*Ongoing symptoms/complications (respiratory distress, chest pain, pulmonary edema, myocardial ischemia)
			*Infusion needed for rate control

			===Discharge===
			*Consider consult with cardiology prior
			*Patients with good rate/rhythm control and anticoagulation can usually be discharged after an appropriate work-up
			*Ensure follow-up is arranged

	==See Also==		==See Also==

Blsimpso: /* External Links */

2021-06-30T15:47:08Z

External Links

← Older revision		Revision as of 15:47, 30 June 2021
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	==External Links==		==External Links==
			*[https://emcrit.org/ibcc/af/ IBCC - Atrial Fibrillation and Flutter complicating critical illness]

	==References==		==References==

Elcatracho: /* See Also */

2021-02-20T18:59:28Z

Elcatracho: /* ECG */

2021-02-01T19:36:56Z

ECG

← Older revision		Revision as of 19:36, 1 February 2021
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	===[[ECG]]===		===[[ECG]]===
	*Narrow complex tachycardia		*Narrow complex tachycardia
			**Usually regular unless variable AV conduction present
	*Atrial rate near 300		*Atrial rate near 300
	*Flutter waves (sawtooth pattern) in inferior leads		*Flutter waves (sawtooth pattern) in inferior leads

ClaireLewis: /* Unstable */

2019-09-23T23:46:09Z

Unstable

← Older revision		Revision as of 23:46, 23 September 2019
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	#Verify not preexcitation		#Verify not preexcitation
	#Increase diastolic BP to perfuse the heart		#Increase diastolic BP to perfuse the heart
	#*Push-dose [[~~phenylepherine~~]]		#*Push-dose [[phenylephrine]]
	#**Will maintain BP when give rate-control medications		#**Will maintain BP when give rate-control medications
	#**50-200mcg q2-5min with goal DBP >60		#**50-200mcg q2-5min with goal DBP >60

← Older revision		Revision as of 18:59, 20 February 2021
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	==See Also==		==See Also==
	[[Atrial fibrillation]]		*[[Atrial fibrillation]]
			*[[In-Training Exam Review]]

	==External Links==		==External Links==