II. Pathophysiology
- Right atrial reentry circuit around the tricuspid ring
- Macro-reentry Tachycardia
- Reentry around the entire atrium
- Contrast with micro reentry circuits around smaller regions (e.g. AV Node)
III. Types
- Type I Atrial Flutter (typical)
- Constant atrial rate of 240 to 350 beats per minute
- Natural rate is altered by age, atrial dilation and Antiarrhythmics (esp. Type Ia or Type Ic)
- Ventricular rate will usually be at least a 2:1 block (or 3:1 or 4:1)
- AV Node prevents rates above 180
- Type II
- Constant atrial rate at 340 to 440 beats per minute (Faster Atrial Flutter rate than with Type I)
- Differs from Type I in reentry accessory path
IV. Signs
- Constant atrial rate
- Atrial to ventricular rates may range from 1:1 to 4:1
- Atrial to ventricular rate 2 to 1 (most common)
- Atrial rate of 240 to 350 beats per minute
- Ventricular rate 140-150 beats per minute
V. Differential Diagnosis
-
Atrial Fibrillation
- Irregular rhythm without Flutter Waves
- Patient may fluctuate between Atrial Fibrillation and Atrial Flutter on the same EKG
- Sinus Rhythm
- Flutter Wave may be difficult to identify in 2:1 block, and regular rhythm at 150 bpm may be mistaken for NSR
- Atrial Flutter is typically obvious with 3:1 or 4:1 blocks in which the Flutter Waves are easily identified
- However, sinus rhythm responds to specific management for cause (e.g. IV fluids in Dehydration)
- Atrial Flutter, in contrast will maintain a contant ventricular rate
- Flutter Wave may be difficult to identify in 2:1 block, and regular rhythm at 150 bpm may be mistaken for NSR
VI. Diagnostics: EKG
- Constant atrial rate
- Atrial rate: 300 per minute (typical)
- Atrial to ventricular rate
- Ratio 1:1 - 300 bpm (Rare, but potentially lethal)
- Ratio 2:1 - 150 bpm (most common)
- Ratio 3:1 - 100 bpm
- Ratio 4:1 - 75 bpm
- Saw tooth Flutter Waves (F Wave)
- Flutter Waves are best seen in the inferior leads
- May be difficult to visualize at a 2:1 AV Block (rate 140-150) due to overlapping QRS Complex with Flutter Wave
- Increase EKG "paper speed" to 50 mm/sec (rapid) to spread out complexes (P Waves may be seen)
- Images
VII. Management
- See Atrial Fibrillation Management
- Highly responsive to Synchronized Cardioversion at low energy levels
- Dr. Amal Mattu (paraphrased): "you could rub your shoes on the carpet to shock Atrial Flutter back to sinus"
- However Atrial Flutter is often resistant to rate control agents (Metoprolol, Diltiazem)
VIII. References
- Berberian (2023) Crit Dec Emerg Med 37(3): 14-5
Images: Related links to external sites (from Bing)
Related Studies
| Definition (NCI) | A disorder characterized by an electrocardiographic finding of an organized, regular atrial rhythm with atrial rate of 240-340 beats per minute. Multiple P waves typically appear in the inferior leads in a saw tooth-like pattern between the QRS complexes. (CDISC) |
| Definition (NCI_CTCAE) | A disorder characterized by a dysrhythmia with organized rhythmic atrial contractions with a rate of 200-300 beats per minute. The rhythm disturbance originates in the atria. |
| Definition (MSH) | Rapid, irregular atrial contractions caused by a block of electrical impulse conduction in the right atrium and a reentrant wave front traveling up the inter-atrial septum and down the right atrial free wall or vice versa. Unlike ATRIAL FIBRILLATION which is caused by abnormal impulse generation, typical atrial flutter is caused by abnormal impulse conduction. As in atrial fibrillation, patients with atrial flutter cannot effectively pump blood into the lower chambers of the heart (HEART VENTRICLES). |
| Concepts | Pathologic Function (T046) |
| MSH | D001282 |
| ICD9 | 427.32 |
| SnomedCT | 266306001, 155364009, 5370000 |
| LNC | LA17085-4 |
| English | Atrial Flutters, Auricular Flutter, Auricular Flutters, Flutter, Atrial, Flutter, Auricular, Flutters, Atrial, Flutters, Auricular, Atrial Flutter, atrial flutter (diagnosis), atrial flutter, Flutter atrial, Atrial Flutter [Disease/Finding], Flutter;atrial, flutter auricular, Flutter - atrial, ATRIAL FLUTTER, Atrial flutter, Atrial flutter (disorder), atrium; flutter, auricular; flutter |
| French | FLUTTER AURICULAIRE, Flutter auriculaire, Flutter atrial |
| Portuguese | FLUTTER AURICULAR, Flutter Auricular, Flutter auricular, Flutter Atrial |
| Dutch | atriumflutter, atrium; flutter, auriculair; flutter, atriale flutter, Atriumfladderen, Boezemfladderen, Fladderen, boezem- |
| German | Flattern Vorhof, Vorhofflattern, Aurikuläres Flattern |
| Swedish | Förmaksfladder |
| Japanese | ｼﾝﾎﾞｳｿﾄﾞｳ, 心房粗動 |
| Czech | kmitání síní, Flutter síní, FLS, síňový flutter, flutter síní |
| Spanish | Aleteo Auricular, Aleteo Atrial, Flúter auricular, Flutter atrial, Flutter Auricular, Flúter atrial, aleteo auricular (trastorno), aleteo auricular, flúter auricular, taquisistolia auricular, Aleteo auricular |
| Finnish | Eteislepatus |
| Russian | USHKA PREDSERDIIA TREPETANIE, PREDSERDII TREPETANIE, TREPETANIE PREDSERDII, ПРЕДСЕРДИЙ ТРЕПЕТАНИЕ, ТРЕПЕТАНИЕ ПРЕДСЕРДИЙ, УШКА ПРЕДСЕРДИЯ ТРЕПЕТАНИЕ |
| Italian | Flutter auricolare, Flutter atriale |
| Polish | Trzepotanie przedsionków |
| Hungarian | Pitvari fluttern, Atrialis flutter |
| Norwegian | Atrieflutter |
Ontology: ECG: F wave - finding (C0429081)
| Concepts | Laboratory or Test Result (T034) |
| SnomedCT | 164943006, 142112008, 142109005, 164940009 |
| English | ECG: F wave, ECG: F wave NOS, ECG: F wave NOS (finding), Electrocardiogram: F wave NOS (finding), ECG: F wave (finding), Electrocardiogram: F wave NOS, ECG: F wave NOS (observable entity), Finding of ECG F wave (finding), Finding of electrocardiogram F wave, Finding of electrocardiogram F wave (finding), ECG: F wave - finding |
| Spanish | electrocardiograma: onda F, SAI, electrocardiograma: onda F, SAI (entidad observable), electrocardiograma: onda F, SAI (hallazgo), ECG: onda F, SAI, ECG: F wave NOS, electrocardiograma: onda F - hallazgo, ECG: onda F - hallazgo, electrocardiograma: onda F - hallazgo (hallazgo) |
