Internal Medicine

P1: SBT

0521779407-05 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:49

192 Atrial Flutter

➣Atypical atrial flutter: includes a wide variety of non-CTI-

dependent flutter. Not easily diagnosed by surface ECG: may

mimic CTI-dependent flutter or no identifiable discrete flutter

waves due to extensive atrial disease. Flutter wave rate >300/min.

Unstable and may deteriorate to AF.

■Specific Diagnostic Tests:

➣Echocardiogram to identify structural heart disease

➣Electrophysiology study to confirm type of atrial flutter (usually

performed in conjunction with RF ablation)

differential diagnosis

■Sinus tachycardia, supraventricular tachycardia (SVT), and atrial

tachycardia

■Carotid sinus message or adenosine IV: increased AV block enables

better identification of flutter waves. May terminate reentrant SVTs

such as AV nodal reentrant tachycardia, AV reentrant tachycardia

and atrial tachycardia, but not atrial flutter.

■Distinguish from atrial tachycardia by characteristic form and rates

of the flutter waves on surface ECG.

■Diagnostic electrophysiology study possibly required

management

What to Do First

■Vital signs to assess hemodynamic response to rapid atrial flutter;

12-lead ECG to assess for acute myocardial ischemia, infarction or

pericarditis

General Measures

■Avoid caffeine and alcohol, if correlated with atrial flutter occurr-

ence.

specific therapy

Indicated for rapid ventricular response and restoration of sinus

rhythm

Acute

■Emergency DC cardioversion (synchronized to R wave) to restore

NSR when rapid ventricular response results in hypotension, pul-

monary edema, or ischemia