5/2/2015

AtrialFlutter

AtrialFlutter
Author:LawrenceRosenthal,MD,PhD,FACC,FHRSChiefEditor:JeffreyNRottman,MDmore...
Updated:Mar27,2014

PracticeEssentials
Atrialflutterisacardiacarrhythmiacharacterizedbyatrialratesof240400beats/minandsomedegreeof
atrioventricular(AV)nodeconductionblock.Forthemostpart,morbidityandmortalityareduetocomplicationsof
rate(eg,syncopeandcongestiveheartfailure[CHF]).Seetheimagebelow.

Anatomyofclassiccounterclockwiseatrialflutter.Thisdemonstratesobliqueviewofrightatriumandshowssomecrucial
structures.Isthmusoftissueresponsibleforatrialflutterisseenanteriortocoronarysinusorifice.Eustachianridgeispartofcrista
terminalisthatseparatesroughenedpartofrightatriumfromsmoothseptalpartofrightatrium.

Signsandsymptoms
Signsandsymptomsinpatientswithatrialfluttertypicallyreflectdecreasedcardiacoutputasaresultoftherapid
ventricularrate.Typicalsymptomsincludethefollowing:
Palpitations
Fatigueorpoorexercisetolerance
Milddyspnea
Presyncope
Lesscommonsymptomsincludeangina,profounddyspnea,orsyncope.Tachycardiamayormaynotbepresent,
dependingonthedegreeofAVblockassociatedwiththeatrialflutteractivity.
Physicalfindingsincludethefollowing:
Theheartrateisoftenapproximately150beats/minbecauseofa2:1AVblock
Thepulsemayberegularorslightlyirregular
Hypotensionispossible,butnormalbloodpressureismorecommonlyobserved
Otherpointsinthephysicalexaminationareasfollows:
Palpatetheneckandthyroidglandforgoiter
Evaluatetheneckforjugularvenousdistention
Auscultatethelungsforralesorcrackles
Auscultatetheheartforextraheartsoundsandmurmurs
Palpatethepointofmaximumimpulseonthechestwall
Assessthelowerextremitiesforedemaorimpairedperfusion
Ifembolizationhasoccurredfromintermittentatrialflutter,findingsarerelatedtobrainorperipheralvascular
involvement.Othercomplicationsofatrialfluttermayincludethefollowing:
CHF
Severebradycardia
Myocardialraterelatedischemia
SeePresentationformoredetail.

Diagnosis
Thefollowingtechniquesaidinthediagnosisofatrialflutter:
ECGThisisanessentialdiagnosticmodalityforthiscondition
VagalmaneuversThesecanbehelpfulindeterminingtheunderlyingatrialrhythmifflutterwavesarenot
seenwell
AdenosineThiscanbehelpfulinthediagnosisofatrialflutterbytransientlyblockingtheAVnode
ExercisetestingThiscanbeutilizedtoidentifyexerciseinducedatrialfibrillationandtoevaluateischemic
heartdisease
HoltermonitorThiscanbeusedtohelpidentifyarrhythmiasinpatientswithnonspecificsymptoms,to
identifytriggers,andtodetectassociatedatrialarrhythmias
Transthoracicechocardiography(TTE)isthepreferredmodalityforevaluatingatrialflutter.Itcanevaluaterightand
leftatrialsize,aswellasthesizeandfunctionoftherightandleftventricles,andthisinformationfacilitates

http://emedicine.medscape.com/article/151210overview#aw2aab6b2b2

1/6

5/2/2015

AtrialFlutter

diagnosisofvalvularheartdisease,leftventricularhypertrophy(LVH),andpericardialdisease.
SeeWorkupformoredetail.

Management
Generaltreatmentgoalsforsymptomaticatrialflutteraresimilartothoseforatrialfibrillation.Theyincludethe
following:
ControlofventricularrateThiscanbeachievedwithdrugsthatblocktheAVnodeintravenous(IV)
calciumchannelblockers(eg,verapamilanddiltiazem)orbetablockerscanbeused,followedbyinitiationof
oralagents
RestorationofsinusrhythmThiscanbedonebymeansofelectricalorpharmacologiccardioversionor
RFAsuccessfulablationreducesoreliminatestheneedforlongtermanticoagulationandantiarrhythmic
medications
PreventionofrecurrentepisodesordecreaseintheirfrequencyordurationIngeneral,theuseof
antiarrhythmicdrugsinatrialflutterissimilartothatinatrialfibrillation
PreventionofthromboemboliccomplicationsAdequateanticoagulation,asrecommendedbytheAmerican
CollegeofChestPhysicians,hasbeenshowntodecreasethromboemboliccomplicationsinpatientswith
chronicatrialflutterandinpatientsundergoingcardioversion
MinimizationofadverseeffectsfromtherapyBecauseatrialflutterisanonfatalarrhythmia,carefully
assesstherisksandbenefitsofdrugtherapy,especiallywithantiarrhythmicagents
SeeTreatmentandMedicationformoredetail.

Background
Atrialflutterisacardiacarrhythmiacharacterizedbyatrialratesof240400beats/min,usuallywithsomedegreeof
atrioventricular(AV)nodeconductionblock.Inthemostcommonformofatrialflutter(typeIatrialflutter),
electrocardiography(ECG)demonstratesanegativesawtoothpatterninleadsII,III,andaVF.
TypeI(typicalorclassic)atrialflutterinvolvesasinglereentrantcircuitwithcircusactivationintherightatrium
aroundthetricuspidvalveannulus.Thecircuitmostoftentravelsinacounterclockwisedirection.TypeII(atypical)
atrialflutterfollowsadifferentcircuititmayinvolvetherightortheleftatrium.(SeePathophysiology.)
Atrialflutterisassociatedwithavarietyofcardiacdisorders.Inmoststudies,approximately60%ofpatientswith
atrialflutterhavecoronaryarterydisease(CAD)orhypertensiveheartdisease30%havenounderlyingcardiac
disease.Uncommonformsofatrialflutterhavebeennotedduringlongtermfollowupinasmanyas26%of
patientswithsurgicalcorrectionofcongenitalcardiacanomalies.(SeeEtiology.)
Symptomsinpatientswithatrialfluttertypicallyreflectdecreasedcardiacoutputasaresultoftherapidventricular
rate.Themostcommonsymptomispalpitations.Othersymptomsincludefatigue,dyspnea,andchestpain.(See
Presentation.)ECGisessentialinmakingthediagnosis.Transthoracicechocardiography(TTE)isthepreferred
modalityforevaluatingatrialflutter.(SeeWorkup.)
Interveningtocontroltheventricularresponserateortoreturnthepatienttosinusrhythmisimportant.Consider
immediateelectricalcardioversionforpatientswhoarehemodynamicallyunstable.Considercatheterbasedablation
asfirstlinetherapyinpatientswithtypeItypicalatrialflutteriftheyarereasonablecandidates.Ablationisusually
doneasanelectiveprocedurehowever,itcanalsobedonewhenthepatientisinatrialflutter.(SeeTreatment.)
Atrialflutterissimilartoatrialfibrillationinmanyrespects(eg,underlyingdisease,predisposingfactors,
complications,andmedicalmanagement),andsomepatientshavebothatrialflutterandatrialfibrillation.However,
theunderlyingmechanismofatrialfluttermakesthisarrhythmiaamenabletocurewithpercutaneouscatheterbased
techniques.

Pathophysiology
Inhumans,themostcommonformofatrialflutter(typeI)involvesasinglereentrantcircuitwithcircusactivationin
therightatriumaroundthetricuspidvalveannulus(mostofteninacounterclockwisedirection),withanareaofslow
conductionlocatedbetweenthetricuspidvalveannulusandthecoronarysinusostium(subeustachianisthmus).A3
dimensionalelectroanatomicmapoftypeIatrialflutterisshowninthevideobelow.
3DimensionalelectroanatomicmapoftypeIatrialflutter.Colorsprogressfrombluetoredtowhiteandrepresentrelativeconduction
timeinrightatrium(earlytolate).Ablationline(reddots)hasbeencreatedontricuspidridgeextendingtoinferiorvenacava.This
interruptsfluttercircuit.RAA=rightatrialappendageCSO=coronarysinusosIVC=inferiorvenacavaTV=tricuspidvalve
annulus.

Animalmodelshavebeenusedtodemonstratethatananatomicblock(surgicallycreated)orafunctionalblockof
conductionbetweenthesuperiorvenacavaandtheinferiorvenacava,similartothecristaterminalisinthehuman
rightatrium,iskeytoinitiatingandmaintainingthearrhythmia.
Thecristaterminalisactsasanotheranatomicconductionbarrier,similartothelineofconductionblockbetweenthe
2venaecavaerequiredintheanimalmodel.Theorificesofbothvenaecavae,theeustachianridge,thecoronary
sinusorifice,andthetricuspidannuluscompletethebarrierforthereentrycircuit(seetheimagebelow).TypeI
atrialflutterisoftenreferredtoasisthmusdependentflutter.Usually,therhythmisduetoreentry,thereisan
excitablegap,andtherhythmcanbeentrained.

http://emedicine.medscape.com/article/151210overview#aw2aab6b2b2

2/6

5/2/2015

AtrialFlutter

Anatomyofclassiccounterclockwiseatrialflutter.Thisdemonstratesobliqueviewofrightatriumandshowssomecrucial
structures.Isthmusoftissueresponsibleforatrialflutterisseenanteriortocoronarysinusorifice.Eustachianridgeispartofcrista
terminalisthatseparatesroughenedpartofrightatriumfromsmoothseptalpartofrightatrium.

TypeIcounterclockwiseatrialflutterhascaudocranialactivation(ie,activationcounterclockwisearoundthetricuspid
valveannuluswhenviewedintheleftanteroobliquefluoroscopicview)oftheatrialseptum(seetheimagebelow).

TypeIcounterclockwiseatrialflutter.This3dimensionalelectroanatomicmapoftricuspidvalveandrightatriumshowsactivation
patterndisplayedincolorformat.Redisearlyandblueislate,relativetofixedpointintime.Activationtravelsincounterclockwise
direction.

TypeIatrialfluttercanalsohavetheoppositeactivationsequence(ie,clockwiseactivationaroundthetricuspid
valveannulus).Clockwiseatrialflutterismuchlesscommon.Whentheelectricactivitymovesinaclockwise
direction,theECGwillshowpositiveflutterwavesinleadsII,III,andaVFandmayappearsomewhatsinusoidal.
ThisarrhythmiaisstillconsideredtypeI,isthmusdependentflutteritisusuallycalledreversetypicalatrialflutter.
TypeII(atypical)atrialfluttersarelessextensivelystudiedandelectroanatomicallycharacterized.Atypicalatrial
fluttersmayoriginatefromtherightatrium,asaresultofsurgicalscars(ie,incisionalreentry),orfromtheleft
atrium,specificallythepulmonaryveins(ie,focalreentry)ormitralannulus(seetheimagebelow).Leftatrialflutter
iscommonafterincompleteleftatriallinearablationprocedures(foratrialfibrillation).Thus,tricuspidisthmus
dependencyisnotaprerequisitefortypeIIatrialflutter.

Atypicalleftatrialflutter.

Etiology
Atrialflutterisassociatedwithavarietyofcardiacdisorders.Inmoststudies,approximately30%ofpatientswith
atrialflutterhaveCAD,30%havehypertensiveheartdisease,and30%havenounderlyingcardiacdisease.
Rheumaticheartdisease,congenitalheartdisease,pericarditis,andcardiomyopathymayalsoleadtoatrialflutter.
Rarely,mitralvalveprolapseoracutemyocardialinfarction(MI)hasbeenassociatedwithatrialflutter.
Inaddition,thefollowingconditionsarealsoassociatedwithatrialflutter:
Hypoxia
Chronicobstructivepulmonarydisease(COPD)
Pulmonaryembolism
Hyperthyroidism
Pheochromocytoma
Diabetes
Electrolyteimbalance
Alcoholconsumption
Obesity
Digitalistoxicity
Myotonicdystrophyinchildhood(rare) [1]
Atrialfluttermaybeasequelaofopenheartsurgery.Aftercardiacsurgery,atrialfluttermaybereentrantasaresult
ofnaturalbarriers,atrialincisions,andscar.Somepatientsdevelopatypicalleftatrialflutterafterpulmonaryvein
isolationforatrialfibrillation.
Althoughtherearenoclearlydefinedgeneticconditionsthatcauseatrialflutter,inmanycasesthereislikelyan
underlyinggeneticsusceptibilitytoacquiringit.Genomewideassociationstudies(GWAS)haveidentifiedgenes
associatedwithatrialflutter. [2]
ThePITX2(pairedlikehomeodomain2)geneonchromosomelocus4q25isknowntoplayamajorroleinleftright
asymmetryoftheheartandhasbeenfoundtohaveastrongassociationwithatrialfibrillation[3]andaneven
strongerassociationwithtypicalatrialflutter. [4]Therearenotyetanyclinicallyavailablegeneticteststhatcan
identifypersonsatincreasedriskforatrialflutter.

http://emedicine.medscape.com/article/151210overview#aw2aab6b2b2

3/6

5/2/2015

AtrialFlutter

Epidemiology
UnitedStatesstatistics
Atrialflutterismuchlesscommonthanatrialfibrillation.OfthepatientsadmittedtoUShospitalswithadiagnosis
ofsupraventriculartachycardiabetween1985and1990,77%hadatrialfibrillationand10%hadatrialflutter.Onthe
basisofastudyofpatientsreferredtotertiarycarecenters,theincidenceofatrialflutterintheUnitedStatesis
estimatedtobeapproximately200,000newcasesperyear. [5]

Sexandagerelateddemographics
Inastudyof100patientswithatrialflutter,75%weremen.Inanotherstudyperformedatatertiarycarestudy,
atrialflutterwas2.5timesmorecommoninmen.
Patientswithatrialflutter,aswithatrialfibrillation,tendtobeolderadults.Inonestudy,theaverageagewas64
years.Theprevalenceofatrialfibrillationincreaseswithage,asfollows:
2535years:23casesper1000population
5564years:3090casesper1000population
6590years:5090casesper1000population

Prognosis
Theprognosisforatrialflutterdependsonthepatientsunderlyingmedicalcondition.Anyprolongedatrial
arrhythmiacancauseatachycardiainducedcardiomyopathy.Interveningtocontroltheventricularresponserateor
toreturnthepatienttosinusrhythmisimportant.Thrombusformationintheleftatriumhasbeendescribedin
patientswithatrialflutter(021%).Thromboemboliccomplicationshavealsobeendescribed. [6]
BecauseoftheconductionpropertiesoftheAVnode,manypeoplewithatrialflutterwillhaveafasterventricular
responsethanthosewithatrialfibrillation.Theheartrateisoftenmoredifficulttocontrolwithatrialflutterthanwith
atrialfibrillation,becauseofincreasedconcealedconductioninthosewithatrialfibrillation.
Forthemostpart,morbidityandmortalityresultfromcomplicationsofrate(eg,syncopeandcongestiveheart
failure[CHF]).Inpatientswithatrialflutter,theriskofembolicoccurrencesapproachesthatseeninatrialfibrillation.
PatientswithWolffParkinsonWhitesyndromewhodevelopatrialfluttercandeveloplifethreateningventricular
responsesandthereforeshouldbeconsideredforcatheterablationoftheiraccessorybypasstract.
DatafromtheFraminghamstudysuggestthatpatientswithatrialfibrillationdonotliveaslongaspatientswithout
atrialfibrillation(ie,controlsubjects).Nodataareavailableonatrialflutter.
TheprognosisforpatientswithtypeIatrialflutterwhoundergocatheterablationisexcellent,withaverylow
recurrencerate.Thepictureisnotasclearforpatientswithbothatrialflutterandatrialfibrillation.Somereports
havedocumentedfewerepisodesofatrialfibrillationaftersuccessfulflutterablationothershavenot.Itispossible
thatatrialfibrillationmaybemoreresponsivetoantiarrhythmicagentsafteratrialflutterhasbeeneliminated.
Bohnenetalperformedaprospectivestudytoassesstheincidenceandpredictorsofmajorcomplicationsfrom
contemporarycatheterablationprocedures. [7]Majorcomplicationratesrangedfrom0.8%(supraventricular
tachycardia)to6%(ventriculartachycardiaassociatedwithstructuralheartdisease),dependingontheablation
procedureperformed.Renalinsufficiencywastheonlyindependentpredictorofamajorcomplication.
NumerousreportsindicatethatpatientswithatrialfibrillationwhoaregivenclassICantiarrhythmicagentsmay
converttoatrialflutterwithfasterventricularrates.Thus,patientsreceivingtypeICagents(eg,flecainide)should
alsoreceiveanAVnodeblockingdrugsuchasabetablockerorcalciumchannelblocker.Inpatientswithboth
atrialfibrillationandatrialflutter,therelativeriskfordevelopmentofstrokeis4.1%incomparisonwithcontrol
subjects. [8]

PatientEducation
Patienteducationregardingmedicationsanddietisimportant.Patientstakingwarfarinshouldavoidmakingmajor
changesintheirdietuntiltheyhaveconsultedwiththeirhealthcareproviders.Specifically,asuddenchangeinthe
consumptionofgreenleafyvegetables,whicharesourcesofvitaminK,canaffectcoagulationinpatientstaking
warfarin,whichinhibitsvitaminKsynthesis.Thiseducationisnotneededwithnewerdrugsthatavoidthesedrug
drugordrugfoodinteractions.
Forpatienteducationinformation,seetheHeartHealthCenter,aswellasAtrialFlutter,HeartRhythmDisorders,
Stroke,SupraventricularTachycardia,andPalpitations.

ContributorInformationandDisclosures
Author
LawrenceRosenthal,MD,PhD,FACC,FHRSAssociateProfessorofMedicine,Director,SectionofCardiac
PacingandElectrophysiology,DirectorofEPFellowshipProgram,DivisionofCardiovascularDisease,University
ofMassachusettsMemorialMedicalCenter
LawrenceRosenthal,MD,PhD,FACC,FHRSisamemberofthefollowingmedicalsocieties:AmericanCollege
ofCardiology,AmericanHeartAssociation,andMassachusettsMedicalSociety
Disclosure:Nothingtodisclose.
Coauthor(s)
CynthiaAnneEnnis,DOAssistantProfessor,UniversityofMassachusettsMedicalCenter
Disclosure:Nothingtodisclose.
ChiefEditor
JeffreyNRottman,MDProfessorofMedicineandPharmacology,VanderbiltUniversitySchoolofMedicine

http://emedicine.medscape.com/article/151210overview#aw2aab6b2b2

4/6

5/2/2015

AtrialFlutter

Chief,DepartmentofCardiology,NashvilleVeteransAffairsMedicalCenter
JeffreyNRottman,MDisamemberofthefollowingmedicalsocieties:AmericanHeartAssociationandNorth
AmericanSocietyofPacingandElectrophysiology
Disclosure:Nothingtodisclose.
AdditionalContributors
BrianOlshansky,MDProfessorofMedicine,DepartmentofInternalMedicine,UniversityofIowaCollegeof
Medicine
BrianOlshansky,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofCardiology,American
HeartAssociation,CardiacElectrophysiologySociety,andHeartRhythmSociety
Disclosure:Guidant/BostonScientificHonorariaSpeakingandteachingMedtronicHonorariaSpeakingand
teachingGuidant/BostonScientificConsultingfeeConsulting
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment

References
1. SudaK,MatsumuraM,HayashiY.Myotonicdystrophypresentingasatrialflutterinchildhood.Cardiol
Young.Feb200414(1):8992.[Medline].
2. IoannidisJP.Predictionofcardiovasculardiseaseoutcomesandestablishedcardiovascularriskfactorsby
genomewideassociationmarkers.CircCardiovascGenet.Feb20092(1):715.[Medline].
3. OlesenMS,HolstAG,JabbariJ,NielsenJB,ChristophersenIE,SajadiehA,etal.Geneticlocion
chromosomes4q25,7p31,and12p12areassociatedwithonsetofloneatrialfibrillationbeforetheageof
40years.CanJCardiol.MarApr201228(2):1915.[Medline].
4. GudbjartssonDF,ArnarDO,HelgadottirA,GretarsdottirS,HolmH,SigurdssonA,etal.Variants
conferringriskofatrialfibrillationonchromosome4q25.Nature.Jul192007448(7151):3537.[Medline].
5. GranadaJ,UribeW,ChyouPH,MaassenK,VierkantR,SmithPN,etal.Incidenceandpredictorsofatrial
flutterinthegeneralpopulation.JAmCollCardiol.Dec200036(7):22426.[Medline].
6. GhaliWA,WasilBI,BrantR,ExnerDV,CornuzJ.Atrialflutterandtheriskofthromboembolism:a
systematicreviewandmetaanalysis.AmJMed.Feb2005118(2):1017.[Medline].
7. BohnenM,StevensonWG,TedrowUB,etal.Incidenceandpredictorsofmajorcomplicationsfrom
contemporarycatheterablationtotreatcardiacarrhythmias.HeartRhythm.Nov20118(11):16616.
[Medline].
8. BibloLA,YuanZ,QuanKJ,MackallJA,RimmAA.Riskofstrokeinpatientswithatrialflutter.AmJ
Cardiol.Feb1200187(3):3469,A9.[Medline].
9. NeumarRW,OttoCW,LinkMS,KronickSL,ShusterM,CallawayCW,etal.Part8:adultadvanced
cardiovascularlifesupport:2010AmericanHeartAssociationGuidelinesforCardiopulmonaryResuscitation
andEmergencyCardiovascularCare.Circulation.Nov22010122(18Suppl3):S72967.[Medline].[Full
Text].
10. MorrisonLJ,DeakinCD,MorleyPT,CallawayCW,KerberRE,KronickSL,etal.Part8:Advancedlife
support:2010InternationalConsensusonCardiopulmonaryResuscitationandEmergencyCardiovascular
CareScienceWithTreatmentRecommendations.Circulation.Oct192010122(16Suppl2):S345421.
[Medline].[FullText].
11. BlomstrmLundqvistC,ScheinmanMM,AliotEM,AlpertJS,CalkinsH,CammAJ,etal.ACC/AHA/ESC
guidelinesforthemanagementofpatientswithsupraventriculararrhythmiasexecutivesummary:areport
oftheAmericanCollegeofCardiology/AmericanHeartAssociationTaskForceonPracticeGuidelinesand
theEuropeanSocietyofCardiologyCommitteeforPracticeGuidelines(WritingCommitteetoDevelop
GuidelinesfortheManagementofPatientsWithSupraventricularArrhythmias).Circulation.Oct14
2003108(15):1871909.[Medline].[FullText].
12. MelsenWG,RoversMM,BontenMJ.Ventilatorassociatedpneumoniaandmortality:asystematicreview
ofobservationalstudies.CritCareMed.Oct200937(10):270918.[Medline].
13. FalkRH,PollakA,SinghSN,FriedrichT.Intravenousdofetilide,aclassIIIantiarrhythmicagent,forthe
terminationofsustainedatrialfibrillationorflutter.IntravenousDofetilideInvestigators.JAmCollCardiol.
Feb199729(2):38590.[Medline].
14. AbiMansourP,CarberryPA,McCowanRJ,HenthornRW,DunnGH,PerryKT.Conversionefficacyand
safetyofrepeateddosesofibutilideinpatientswithatrialflutterandatrialfibrillation.StudyInvestigators.
AmHeartJ.Oct1998136(4Pt1):63242.[Medline].
15. StamblerBS,WoodMA,EllenbogenKA,PerryKT,WakefieldLK,VanderLugtJT.Efficacyandsafetyof
repeatedintravenousdosesofibutilideforrapidconversionofatrialflutterorfibrillation.IbutilideRepeat
DoseStudyInvestigators.Circulation.Oct1199694(7):161321.[Medline].
16. StamblerBS,WoodMA,EllenbogenKA.Antiarrhythmicactionsofintravenousibutilidecomparedwith
procainamideduringhumanatrialflutterandfibrillation:electrophysiologicaldeterminantsofenhanced
conversionefficacy.Circulation.Dec16199796(12):4298306.[Medline].
17. VosMA,GolitsynSR,StanglK,RudaMY,VanWijkLV,HarryJD,etal.Superiorityofibutilide(anew
classIIIagent)overDLsotalolinconvertingatrialflutterandatrialfibrillation.TheIbutilide/Sotalol
ComparatorStudyGroup.Heart.Jun199879(6):56875.[Medline].[FullText].

http://emedicine.medscape.com/article/151210overview#aw2aab6b2b2

5/6

5/2/2015

AtrialFlutter

18. AlboniP,BottoGL,BaldiN,LuziM,RussoV,GianfranchiL,etal.Outpatienttreatmentofrecentonset
atrialfibrillationwiththe"pillinthepocket"approach.NEnglJMed.Dec22004351(23):238491.
[Medline].
19. VosMA,GolitsynSR,StanglK,RudaMY,VanWijkLV,HarryJD,etal.Superiorityofibutilide(anew
classIIIagent)overDLsotalolinconvertingatrialflutterandatrialfibrillation.TheIbutilide/Sotalol
ComparatorStudyGroup.Heart.Jun199879(6):56875.[Medline].[FullText].
20. BergerM,SchweitzerP.Timingofthromboemboliceventsafterelectricalcardioversionofatrialfibrillation
orflutter:aretrospectiveanalysis.AmJCardiol.Dec15199882(12):15457,A8.[Medline].
21. GrimmRA,StewartWJ,ArheartK,ThomasJD,KleinAL.Leftatrialappendage"stunning"afterelectrical
cardioversionofatrialflutter:anattenuatedresponsecomparedwithatrialfibrillationasthemechanismfor
lowersusceptibilitytothromboembolicevents.JAmCollCardiol.Mar1199729(3):5829.[Medline].
22. BertagliaE,ZoppoF,BonsoA,ProclemerA,VerlatoR,CorL,etal.Longtermfollowupof
radiofrequencycatheterablationofatrialflutter:clinicalcourseandpredictorsofatrialfibrillation
occurrence.Heart.Jan200490(1):5963.[Medline].[FullText].
23. BazanV,GrauN,VallesE,FelezM,SanjuasC,CainzosAchiricaM,etal.Obstructivesleepapneain
patientswithtypicalatrialflutter:prevalenceandimpactonarrhythmiacontroloutcome.Chest.May1
2013143(5):127783.[Medline].
24. CoffeyJO,d'AvilaA,DukkipatiS,DanikSB,GangireddySR,KoruthJS,etal.Catheterablationofscar
relatedatypicalatrialflutter.Europace.Mar201315(3):4149.[Medline].
MedscapeReference2011WebMD,LLC

http://emedicine.medscape.com/article/151210overview#aw2aab6b2b2

6/6