Andrade JG, Verma A, Mitchell LB, et al; CCS Atrial Fibrillation Guidelines Committee. 2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol. 2018 Nov;34(11):1371-1392. doi: 10.1016/j.cjca.2018.08.026. PubMed PMID: 30404743.
January CT, Wann LS, Alpert JS, et al; ACC/AHA Task Force Members. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014 Dec 2;130(23):e199-267. doi: 10.1161/CIR.0000000000000041. Epub 2014 Mar 28. Erratum in: Circulation. 2014 Dec 2;130(23):e272-4. PubMed PMID: 24682347; PubMed Central PMCID: PMC4676081.
Priori SG, Wilde AA, Horie M, et al. HRS/EHRA/APHRS expert consensus statement on the diagnosis and management of patients with inherited primary arrhythmia syndromes: document endorsed by HRS, EHRA, and APHRS in May 2013 and by ACCF, AHA, PACES, and AEPC in June 2013. Heart Rhythm. 2013 Dec;10(12):1932-63. doi: 10.1016/j.hrthm.2013.05.014. Epub 2013 Aug 30. Review. PubMed PMID: 24011539.
Brignole M, Auricchio A, Baron-Esquivias G, et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J. 2013 Aug;34(29):2281-329. doi: 10.1093/eurheartj/eht150. Epub 2013 Jun 24. PubMed PMID: 23801822.
American College of Cardiology Foundation; American Heart Association; European Society of Cardiology; Heart Rhythm Society, Wann LS, Curtis AB, Ellenbogen KA, et al. Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation. 2013 May 7;127(18):1916-26. doi: 10.1161/CIR.0b013e318290826d. Epub 2013 Apr 1. PubMed PMID: 23545139.
Camm AJ, Lip GY, De Caterina R, et al; ESC Committee for Practice Guidelines (CPG). 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012 Nov;33(21):2719-47. doi: 10.1093/eurheartj/ehs253. Epub 2012 Aug 24. Erratum in: Eur Heart J. 2013 Mar;34(10):790. Eur Heart J. 2013 Sep;34(36):2850-1. PubMed PMID: 22922413.
Tracy CM, Epstein AE, Darbar D, et al; American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines; Heart Rhythm Society. 2012 ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. [corrected]. Circulation. 2012 Oct 2;126(14):1784-800. doi: 10.1161/CIR.0b013e3182618569. Epub 2012 Sep 10. Erratum in: Circulation. 2013 Jan 22;127(3):e357-9. Heart Rhythm Society [added]. PubMed PMID: 22965336.
Pediatric and Congenital Electrophysiology Society (PACES); Heart Rhythm Society (HRS); American College of Cardiology Foundation (ACCF); American Heart Association (AHA); American Academy of Pediatrics (AAP); Canadian Heart Rhythm Society (CHRS), Cohen MI, Triedman JK, Cannon BC, et al. PACES/HRS expert consensus statement on the management of the asymptomatic young patient with a Wolff-Parkinson-White (WPW, ventricular preexcitation) electrocardiographic pattern: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), the American Academy of Pediatrics (AAP), and the Canadian Heart Rhythm Society (CHRS). Heart Rhythm. 2012 Jun;9(6):1006-24. doi: 10.1016/j.hrthm.2012.03.050. Epub 2012 May 10. PubMed PMID: 22579340.
European Heart Rhythm Association; European Association for Cardio-Thoracic Surgery, Camm AJ, Kirchhof P, Lip GY, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010 Oct;31(19):2369-429. doi: 10.1093/eurheartj/ehq278. Epub 2010 Aug 29. Erratum in: Eur Heart J. 2011 May;32(9):1172. PubMed PMID: 20802247.
Definition, Etiology, PathogenesisTop
Atrial flutter (AFL) is a macroreentrant arrhythmia (spinning around a large circuit in the atrium) characterized by a regular atrial rate (usually 250-300 beats/min) and a constant P wave morphology. Paroxysmal AFL can occur in patients with no apparent structural heart disease, whereas chronic AFL is usually associated with preexisting conditions, such as valvular or ischemic heart disease or cardiomyopathy. Those at the highest risk of developing AFL are men, older adults, and individuals with preexisting heart failure or chronic obstructive pulmonary disease. In ~60% of cases AFL occurs as part of an acute disease process.
In >90% of patients with AFL, the AFL circuit involves the cavotricuspid isthmus (CTI), which is the critical area for sustaining the flutter and where efforts to ablate may be directed. AFL can occur in clinical settings similar to those associated with atrial fibrillation (AF) and may be triggered by atrial tachycardia (AT) or AF. Non–CTI-dependent flutter is called atypical and is commonly seen in patients with previous AF ablation, severe left atrial disease, or previous atrial surgery.
Clinical Features and Natural HistoryTop
AFL is frequently recurrent and attacks are usually accompanied by tachyarrhythmia. Some patients may be asymptomatic in chronic AFL. Antiarrhythmic drugs and heart rate medications are less effective in AFL than in other types of supraventricular arrhythmias and thus a general recommendation is to either combine atrioventricular (AV) nodal blockers if rate control is intended or consider electrical cardioversion.
In individuals with AF treated with class Ic drugs (Table 3.4-1), there is a small risk of AF organizing into AFL, and this is the reason why flecainide should always be associated with an AV nodal blocker. This is not the case for propafenone.
Clinical signs and symptoms largely depend on the type and severity of the underlying condition and include palpitations (most commonly), dyspnea, weakness, or chest pain. Some patients may be asymptomatic. Heart rates are fast (~150 beats/min) and regular.
Electrocardiography (ECG): Typical AFL (CTI-dependent, counterclockwise rotation around the tricuspid valve) is characterized by dominant negative flutter waves in the inferior leads and a positive P wave in lead V1. Reverse typical AFL (CTI-dependent, counterclockwise rotation around the valve) shows the opposite pattern, with a positive flutter wave in the inferior leads and a negative P wave in lead V1. Carotid sinus massage or adenosine can be useful to transiently increase the degree of the AV block and facilitate diagnosis.
Supraventricular tachycardia: Figure 3.4-2.
Narrow-QRS tachycardia: Figure 3.4-3.
Wide-QRS tachycardia: Figure 3.4-4.
Classification of antiarrhythmic drugs: Table 3.4-1.
Antiarrhythmic agents: Table 3.4-2.
AFL treatment algorithm: Figure 3.4-9.
1. Electrical cardioversion: AFL does not respond well to drugs in general. Electrical cardioversion should be considered early in the management of patents with AFL. Usually a low-energy (50-100 J) shock is used. Prevention of thromboembolism is used as in AF (see Atrial Fibrillation).
2. Pharmacologic treatment: Figure 3.4-9.
Guidelines for drug selection (Figure 3.4-9) are similar to those used in AF, but the effectiveness of antiarrhythmic drugs is significantly inferior to ablation and lower than when used for AF. Rate control may also be difficult to achieve in AFL. In CTI-dependent AFL, catheter ablation has a high success rate with a very low complication rate and may be offered even to patients after a first well-tolerated AFL attack. In atypical AFL, ablation is a more complex procedure with higher recurrence rates and should be considered depending on the patient’s profile.
AFL increases the risk of thromboembolic complications, including ischemic stroke. Therefore, thromboembolism prevention is required, as in patients with AF (see Atrial Fibrillation).
Figure 3.4-9. Treatment of atrial flutter. Adapted from guidelines by the American College of Cardiology, American Heart Association, and European Society of Cardiology.