Internal Medicine

P1: SBT

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

Atrial Fibrillation (AF) Atrial Flutter 191

■Chronic antiarrhythmic therapy: Routine ECG at regular intervals

to monitor AV conduction, QRS and QT duration and ventricular

arrhythmias. Holter to identify asymptomatic atrial fibrillation or

heart block.

■Ibutilide, sotalol and propafenone require ECG telemetry monitor-

ing at start of Rx.

■Amiodarone: Biannual thyroid function tests and chest x-ray

complications and prognosis

■Thromboembolism from left atrial clots 5–8%/yr in high-risk

patients

■Cardiomyopathy in AF with chronic rapid ventricular response

Atrial Flutter........................................

EDMUND C. KEUNG, MD

history & physical

History

■Chronic or paroxysmal

■Underlying heart disease: rheumatic, coronary, hypertensive heart

disease, mitral valve prolapse, after surgery for congenital heart dis-

ease (incisional reentry)

■COPD, acute alcohol ingestion, digoxin toxicity

Signs & Symptoms

■Palpitation, regular rapid pulse

■No symptoms; or dizziness and hypotension, shortness of breath,

chest pain

■Atrial rate 250 to 300/min. Typical ventricular response: 150 bpm (2:1

AV conduction)

tests

■Basic Tests:

➣12-lead ECG:

➣Cavotricuspid isthmus (CTI) dependent counterclockwise atrial

flutter: predominantly negative flutter waves in leads II, III and

F; (+) flutter waves in V1 and (−)inV6

➣Cavotricuspid isthmus (CTI) dependent clockwise atrial flutter:

predominantly positive flutter waves in II, III and F, (−) in V1 and

(+)inV6