Atrial flutter

P-waves QRS regularity start/ end other characteristics

saw-tooth flutter waves at 300 bpm
flutter normal regular or sudden
(5 mm intervals) most easily seen in
waves (unchanged) irregular (paroxysmal)
the inferior leads (II, III and aVF)

During atrial flutter there is an electrical wave-front flowing in a circuit around the right
atrium. The time it takes to complete a circuit is about 200 ms (5 mm on a standard ECG).
This results in the characteristic saw-toothed flutter waves in the inferior leads (II, III, aVF) at
about 300 bpm. Usually, at least half of these impulses will be blocked by the
atrioventricular (AV) node, resulting in a heart rate of approximately 150 bpm (2:1 block),
100 bpm (3:1 block), 75 bpm (4:1 block) etc, or, often, a combination of all these.

The diagnosis is usually obvious on the ECG but, if not, can be clarified by temporarily
increasing the AV block by vagal manoeuvres (Valsalva [recent article on technique in the
Lancet with video!, carotid sinus massage) or (if you must…) IV adenosine (big cannula (≥
green) in an antecubital vein, ≥6 mg adenosine (fast) and ≥10 mL saline flush (fast)).

These measures will not terminate the flutter (which just carries on going merrily around
the right atrium) but may show enough of the characteristic flutter waves to make the
diagnosis.
Immediate management (similar to atrial fibrillation…)

 If the patient is in extremis (due to the atrial flutter being at a fast rate, rather than a
pneumonia causing the atrial flutter), call an ambulance (in the community) or an
anaesthetist (in hospital) and cardiovert
 If not, reassure…
o Look for a trigger (pneumonia, thyrotoxicosis, myocardial infarction, etc)
o If the patient is in heart failure, admit to hospital, treat with oxygen, IV
diuretics and oral digoxin, before controlling the ventricular rate with a beta-
blocker, eg IV metoprolol (because it’s easily available and short acting) or
diltiazem (if a beta-blocker is really contraindicated)

NB: Flecainide (and similar class Ic drugs) are contraindicated in atrial flutter as they slow
conduction through the atrium without blocking the AV node. This can have the highly
undesirable effect of reducing the flutter rate to approximately 200 bpm but increasing the
ventricular rate from 150 to 200 bpm as the AV node can then conduct 1:1:
Long-term management

 Three priorities (also similar to AF):

1. Ventricular rate control - use a beta-blocker (bisoprolol is good and has a

good 24-hour action, diltiazem if there is a definite absolute contraindication
to beta-blockers – amiodarone is not recommended for rate control in atrial
flutter) aiming for about 90 bpm at rest – NB this will be more difficult to
achieve than in AF and is likely to require specialist referral

2. Reduction of thromboembolic risk – calculate the CHA2DS2-VASc score if 0

(or 1 for female sex) do not prescribe an anticoagulant (or aspirin – not
recommended to reduce stroke risk in atrial flutter). Otherwise, prescribe
warfarin or a non-Vitamin K oral anticoagulant (NOAC). Calculate HAS-BLED
score to identify ways to reduce bleeding risk but even a high score is not a
reason to withhold anticoagulation

3. Rate or rhythm? Some people with atrial flutter can be managed with rate
control and anticoagulation. But it is often difficult to achieve good rate
control and most patients with recurrent or persistent atrial flutter are
managed with electrophysiology study and radiofrequency ablation. This is a
low-risk procedure with a low rate of recurrence