Atrial Flutter

Question 1

Definition?

Answer 1

Atrial flutter is re-entrant atrial tachycardia between 250 to 320 bpm

Question 2

RF?

Answer 2

• Age
• Valvular dysfunction
• Atrial septal defects
• Atrial dilatation
• Recent procedures
• Surgical/post-ablation scarring of atria
• HF
• Hyperthyroidism
• COPD
• Asthma
• Pneumonia

Question 3

ddx?

Answer 3

• AF-ECG shows uncoordinated atrial activation with rapidly oscillating fibrillatory waves that vary in amplitude, shape and timing
Atrial tachycardia-isoelectric intervals between P waves in all leads

Question 4

Epidemiology?

Answer 4

Age: Elderly-over 80’s
Sex: Male, 2.5:1
Ethnicity:
Prevalence:

Question 5

Aetiology?

Answer 5

Macro re-entrant rhythms in the atria

Question 6

CP?

Answer 6

• Most are asymptomatic
• Palpitations, dizziness, syncope, fatigue and dyspnoea
• Symptoms of underlying disease
Tachycardia with regular pulse

Question 7

Pathophysiology?

Answer 7

• Automaticity foci that are meant to serve as a back up to the SAN if it fails, but become irritated and fire at higher frequencies in a cyclical signal-processes to the AVN at the same rate but due to refractory period , the impulses are relayed at the same time as normal
Multiple p waves to one ventricular contraction

Question 8

Investigations-first line?

Answer 8

• ECG
• Anti-clockwise isthmus-dependent flutter-Negatively directed saw-tooth waves in leads II, III and aVF and positive deflections in V1 with atrial rates of 240 to 320 bpm
• Clockwise-opp to above
• TFT-see if hyperthyrodism is cause
• Serum electrolytes-see if cause
CXR-see if infection is cause

Question 9

Investigations-second line?

Answer 9

Pulmonary function tests, cardiac enzymes, PE CT, trans-t echo, atrial electrogram and electrophysiological studies

Question 10

Management-first line?

Answer 10

• synchronised cardioversion/pharm-
  
  • with monophasic shocks using <50 J of energy using pads on chest like a defibrillator , although the higher-energy initial shocks are indicated for emergency therapy
• Beta blocker, CCB or amiodarone
• Anticoagulants-NOAC’s or warfarin or heparin
• Underlying cause

Question 11

Management-second line?

Answer 11

• rapid atrial pacing-
Useful for acute conversion of atrial flutter in patients who have pacing wires in place as part of a permanent pacemaker or an implantable cardioverter-defibrillator, or for temporary atrial pacing after cardiac surgery.

Question 12

ongoing managment?

Answer 12

• Catheter ablation of cavotricuspid isthmus-heat/cold passed through catheter tip inserted into groin bt the vena cava opening and tricuspid valve opening to causes selective ischaemia and so breaking the circuit -failed other methods
• Anticoagulation
• Betablocker or CCB
• Long-term anticoagulation
Anti-arrhythmic therapy-amiodarone, solatol dofetilide

Question 13

Prognosis?

Answer 13

• 60% of cases are acute
• Usually don’t require chronic therapy
• Similar TE risk to AF
Harder to control as not as responsive to anti-arrhythmic agents

Question 14

complications?

Answer 14

• Beta-blocker associated exacerbation of reactive airway disease
• MI
• Stroke
• Bradycardia, hypotension, heart failure, pro-arrhythmia, thyroid,
• catheter ablation,
• pulmonary toxicity
tachycardia-mediated cardiomyopathy