Atrial Flutter

Atrial Flutter Overview

Atrial flutter is an abnormality in the beating of the heart. Such abnormalities, whether in rhythm of heartbeat or
speed of heartbeat, are known as arrhythmias.
The heart is a muscle that pumps the blood through the body.
Each beat of the heart is a very rapid series of 2 contractions.
The first contraction is in the upper chambers, the atria; the second contraction is in the lower chambers, the
ventricles.
The atria receive blood back into the heart and pump it into the ventricles; the ventricles pump the blood out
into the aorta, which feeds all the blood vessels to the body.
The beating of the heart is controlled by electrical impulses.
Under normal circumstances, these impulses are generated by the heart's "natural pacemaker" the sinoatrial
(SA) or sinus node, which is located in the right atrium.
The impulse travels across the atria, generating a contraction.
It pauses very briefly at the atrioventricular (AV) node, which is located in the upper part of the muscular wall
between the 2 ventricles. This delay gives the blood time to move from the atria to the ventricles.
The impulse then moves down and through the ventricles, generating the second ventricular contraction that
pumps the blood out of the ventricles.
Atrial flutter occurs when an abnormal conduction circuit develops inside the right atrium, allowing the atria to beat
excessively fast, about 250-300 beats per minute.
These rapid contractions are slowed when they reach the AV node, but are still too fast (typically about 150
beats per minute, or every other atrial beat getting through the AV node to the ventricles).
This type of rhythm is called tachycardia. Because atrial flutter comes from the atria, it is called a
supraventricular (above the ventricles) tachycardia.
The main danger of atrial flutter is that the heart does not pump blood very well when it is beating too fast.
Vital organs such as the heart muscle and brain may not get enough blood.
This can cause them to fail.
Congestive heart failure, heart attack, and/or stroke all can result.
Atrial flutter can come and go; it is then known as paroxysmal atrial flutter. An episode of atrial flutter usually lasts
hours or days. Less often, atrial flutter is more or less permanent and is known as persistent atrial flutter.
With proper treatment, atrial flutter is rarely life threatening. Complications of atrial flutter can be devastating, but they
usually can be prevented with treatment.

Atrial Flutter Causes

Atrial flutter may be caused by abnormalities or diseases of the heart itself, by a disease elsewhere in the body that
affects the heart, or by consuming substances that change the way electrical impulses are transmitted through the
heart. In a few people, no underlying cause is ever found.

Heart diseases or abnormalities that can cause atrial flutter include the following:
Decreased blood flow to the heart (ischemia) due to coronary heart disease, atherosclerosis, or a blood clot
High blood pressure(hypertension)
Disease of the heart muscle (cardiomyopathy)
Abnormalities of the heart valves (especially the mitral valve)
An abnormally enlarged chamber of the heart (hypertrophy)
After open heart surgery
Diseases elsewhere in the body that affect the heart include the following:
Overactive thyroid gland (hyperthyroidism)
Blood clot in a blood vessel in the lungs (pulmonary embolism)
Chronic (ongoing, long-term) lung diseases (COPD), such as emphysema, that lower the amount of oxygen in
the blood
Substances that may contribute to atrial flutter include the following:
Alcohol (wine, beer, or hard liquor)
Stimulants such as cocaine, amphetamines, diet pills, cold medicines, even caffeine
Atrial flutter is closely related to another arrhythmia called atrial fibrillation. The two sometimes alternate back and
forth.

Atrial Flutter Symptoms

Some people have no symptoms at all with atrial flutter.
Others describe the following symptoms:
Palpitations (rapid heartbeat or a pounding sensation in the chest)
A "fluttering" or tremorlike feeling in the chest
Shortness of breath
Anxiety
People with underlying heart or lung disease who experience atrial flutter may have these and other, more significant
symptoms.

Angina pectoris (chest or heart pains)

Feeling faint or light-headed

Fainting (syncope)

When to Seek Medical Care

If you experience any of the symptoms of atrial flutter, call your health care provider for an appointment.
If you are taking medication for atrial flutter, and you experience any of the signs and symptoms described, call your
health care provider.
If you have been diagnosed and are being treated for atrial flutter, go immediately to a hospital emergency
department if you experience any of the following symptoms:
Severe chest pain
Feeling faint or light-headed
Actual fainting

Exams and Tests

Upon hearing your symptoms, your health care provider (whether your primary care provider or the provider in the
emergency department) will probably suspect an arrhythmia.
Because other conditions can cause similar symptoms, the evaluation will at first focus on ruling out the most
dangerous ones.
Fortunately, there is one simple test that can tell quite a lot about what is happening with the heart.
Electrocardiogram (ECG): The ECG measures and records the electrical impulses that control the beating of the
heart.
The ECG highlights irregularities in these impulses and abnormalities in the heart.
In arrhythmias, the ECG tracings can help pinpoint the type of arrhythmia and where in the heart it comes from.
ECG also shows signs of heart attack, heart ischemia, conduction abnormalities, abnormal heart enlargement
(hypertrophy), and even certain chemical abnormalities in the heart tissue such as potassium and calcium.
People sometimes have symptoms suggesting atrial flutter, but their ECG result in the emergency department or
medical office is normal.
This does not mean that you are "imagining things." It just means that your arrhythmia comes and goes, a very
common condition. It may mean you just have some premature beats, which is benign.
If this happens to you, you may be asked to undergo ambulatory ECG.
The purpose of ambulatory ECG is to get documentation of whether you do or do not have a significant
arrhythmia and what type.
This is important because you cannot receive treatment until your specific arrhythmia type has been identified.
Ambulatory ECG involves wearing a monitoring device for a few days while you go about your normal activities.
The device, known as a Holter monitor, is usually worn around your neck. ECG electrodes are worn on the
chest.
Typically, the device records your heart rhythm on a continual basis for 24-72 hours.
Some health care providers prefer that you wear the device for a longer time, with intermittent recording of your
heart rhythm. This is called an event recorder, which can be turned on by yourself when you feel something

abnormal. Even more rarely, an event recorder can be implanted under the skin and worn for several weeks or
months.
Either method works well. The important thing is to get ECG documentation of your arrhythmia.
Echocardiogram: This is a painless ultrasound test that uses sound waves to make a picture of the inside of the heart
while it is beating and between beats.
This test is done to identify heart valve problems, check ventricular function, or look for blood clots in the atria.
This very safe test uses the same technique used to check a fetus in pregnancy.
This test is not always done in the emergency department.
Occasionally, atrial flutter is detected in people with no symptoms when they are seeing their health care provider
about something else. The health care provider may notice unusual heart sounds or pulse on physical exam and
perform an ECG.

Atrial Flutter Treatment

The goals of treatment are to control the heart rate, restore normal sinus rhythm, prevent future episodes, and
prevent stroke.
Control rate: The first treatment goal is to control the ventricular rate.
If you experience serious clinical symptoms, such as chest pain or congestive heart failure related to the
ventricular rate, the health care provider in the emergency department will decrease your heart rate rapidly with
IV medications or electrical shock (defibrillation).
If you have no serious symptoms, you may be given medications by mouth.
Sometimes you may require a combination of oral medications to control your heart rate.
Surgery may be done to control rate, but this is rare.
Restore and maintain normal sinus rhythm: Some people with newly diagnosed atrial flutter convert to normal sinus
rhythm spontaneously in 24-48 hours. The goal of treatment is to convert the atrial flutter to normal sinus rhythm and
prevent recurrence of atrial flutter.
Not everyone with atrial flutter needs anti-arrhythmic medication.
The frequency with which your arrhythmia returns and the symptoms it causes partly determine whether you
receive anti-arrhythmic medication.
Medical professionals carefully tailor each person's anti-arrhythmic medication(s) to produce the desired clinical
effect without creating unwanted side effects, some potentially lethal.
Prevent future episodes: This is usually done by taking daily medication to keep the heart at a safe and comfortable
rate.
Prevent stroke: Stroke is a devastating complication of atrial flutter. It occurs when a piece of a blood clot formed in
the heart breaks off and travels to the brain, where it blocks blood flow.
Coexisting medical conditions, such as congestive heart failure and mitral valve disease, significantly increase
the risk of stroke.

 Patients with persistent atrial flutter need a "blood-thinning" drug called warfarin to lower this risk. Warfarin
blocks a certain factor in the blood that promotes clotting.
People at lower risk of stroke and those who cannot take warfarin may use aspirin. Aspirin is not without its
own side effects, including bleeding problems and stomach ulcers.

Self-Care at Home
Most people known to have atrial flutter will be taking prescribed medications. Avoid taking any stimulants, and
consult with your health care provider before taking any new medications, herbs, or supplements.
Medical Treatment
The first step in treatment is to restore normal rate and sinus rhythm. There are 2 ways to do this, with medication or
with defibrillation.
Defibrillation: This technique uses electrical current to "shock" the heart back to normal sinus rhythm. This is
sometimes called "DC cardioversion."
This is done by applying a device called an external defibrillator to the chest.
This device uses the paddles familiar to watchers of television medical dramas.
When this is done in a hospital, usually a mild general anesthetic is given first because the electrical shocks are
painful.
Cardioversion works very well; more than 90% of people convert to sinus rhythm. For some, however, this is
not a permanent solution; the arrhythmia comes back.
Cardioversion increases the risk of stroke and thus, if time allows, requires pretreatment with an anticoagulant
medication.
Catheter ablation (radiofrequency ablation): "Ablation" means removal. This technique inactivates the abnormal
conduction pathways in the right atrium.
The abnormal pathway(s) is found, and a catheter is placed at this precise location in the conduction system.
After proper placement, the catheter delivers radiofrequency energy, which burns ("ablates") a portion of the
abnormal electrical conduction pathway. This inactivates the abnormal pathway to provide more consistent flow
of electrical impulses.
This technique is very safe; it works in some people but not all. When it does work, atrial flutter is permanently
cured. It has few complications and, unlike surgery, requires little recovery time.
Medications
The choice of medication depends on the frequency of atrial flutter you have, the underlying cause, your other
medical conditions and overall health, and the other medications you take. The classes of medications used in atrial
flutter are as follows:
Anti-arrhythmic medications: These drugs are used to chemically convert atrial flutter to normal sinus rhythm,
reduce the frequency and duration of atrial flutter episodes, and prevent future episodes. They are often given
to prevent return of atrial flutter after cardioversion. Examples are amiodarone, sotalol, ibutilide, propafenone,
and flecainide.
Digoxin (Lanoxin): This old medication decreases the conductivity of electrical impulses through the SA and AV
nodes, slowing down the heart rate.

 Beta-blockers: These drugs decrease the heart rate by slowing conduction through the AV node, plus they
have a direct anti-arrhythmic effect on the atria.
Calcium channel blockers: These drugs also slow down the heart rate by slowing conduction through the AV
node.
Anticoagulants: These drugs reduce the ability of the blood to clot, thus reducing the risk of an unwanted blood
clot forming in the heart or in a blood vessel. Atrial flutter increases the risk of forming such blood clots.

Next Steps
Outlook
Atrial flutter increases your risk of having a stroke.
When the heart is not pumping properly, some blood may be left behind in the heart. This blood forms a pool
and is more likely to clot than blood that is moving.
A piece of a blood clot in the heart can break off and travel to the brain. There, it can block a blood vessel,
causing a stroke.
The other serious complication of atrial flutter is heart failure.
Rapid beating of the heart over a long time can weaken the heart muscle. This further impairs its pumping
ability.
When the heart can no longer pump enough blood to the body through the blood vessels, this is called heart
failure.
If you experience atrial flutter and are found to have no underlying heart disease, your outlook is generally quite good.
If it occurs once without serious heart or lung disease, most likely you will never have it again. If you do have
underlying heart disease, your atrial flutter may recur. Therefore, you should see a heart specialist (cardiologist).