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c_aflutter

Atrial flutter

Introduction:

  • clinically, atrial flutter is managed similarly as for Atrial Fibrillation with which it is often in association, although of the two, AF is 7-8x more common as a cause for admission.
  • often flutter is not as well tolerated as AF due to the rapid and often difficult to control ventricular rate, especially with minimal exertion.
  • The common form of type I atrial flutter has sawtooth flutter (F) waves, best seen in leads II, III, and aVF, with atrial rates of 240-340 bpm and without an isoelectric interval between these F waves.

often it presents as a HR of 150 due to a atrial rate of 300 with a 2:1 block

  • Variable AV conduction can also be seen (commonly present with 2:1 or 3:1 AV conduction). 
  • With 1:1 AV conduction, hemodynamic collapse may occur.
  • 75% of patients are male
  • most patients are older adults with average age 64yrs
  • 30% have ischaemic heart disease
  • 30% have hypertensive heart disease
  • 30% have no underlying cardiac disease
  • other associations:
    • cardiomyopathy
    • hypoxia
    • COPD
    • thyrotoxicosis
    • phaeochromocytoma
    • electrolyte imbalance
    • alcohol consumption

Mx in the ED:

haemodynamically unstable

  • if rapidly deteriorating, then synchronised reversion
  • if delay in access to synchronised reversion then:
    • metaraminol (Aramine) 0.5mg iv over 1 minute and repeat minutely until either:
      • arrhythmia reversion
      • max dose 5mg metaraminol given
      • systolic BP > 100

diagnosis:

  • when it is not clear from the ECG, vagal manouvres or IV adenosine may block the AV node to display the underlying rhythm
  • is there evidence of, or a history of a pre-excitation syndrome such as WPW - this should be determined because agents that act exclusively at the level of the AV node may enhance accessory pathway conduction and cause rapid ventricular response with 1:1 conduction and ventricular rate of 300/min which may precipitate VF.

ventricular rate control:

termination of sustained episodes:

  • if duration < 48hrs after cardiac consultation, DC reversion is effective in 95% & requires less energy than for AF eg. 50J synchronized
  • IV amiodarone slows rate and may result in reversion
  • other anti-arrhythmics

prevention:

  • avoid precipitants - eg. caffeine, alcohol,
  • anti-arrhythmics as for AF - consider sotalol
  • referral for radiofrequency ablation or surgery if recurrent & problematic

prevention of thrombo-embolic complications:

  • risk is ~14% over 4-5yrs, probably more related to unrecognised associated episodes of AF
  • see AF.
c_aflutter.txt · Last modified: 2013/07/16 17:18 (external edit)