eMedicine Specialties > Cardiology > Arrhythmias

Atrial Flutter: Differential Diagnoses & Workup

Author: Lawrence Rosenthal, MD, PhD, Associate Professor of Medicine, Director, Section of Cardiac Electrophysiology and Pacing, Fellowship Director of Clinical Cardiac Electrophysiology, Department of Internal Medicine, Division of Cardiovascular Medicine, University of Massachusetts Memorial Medical Center
Coauthor(s): Cynthia Anne Ennis, DO, Electrophysiology Fellow, University of Massachusetts Medical Center
Contributor Information and Disclosures

Updated: Aug 3, 2009

Differential Diagnoses

Atrial Fibrillation
Atrial Tachycardia

Other Problems to Be Considered

Artifact from tremor 
Atrial tachycardia with AV block
Atrial tachycardia, multifocal

Workup

Laboratory Studies

  • The history and physical examination findings guide laboratory studies. Asymptomatic hyperthyroidism, especially in elderly patients, can manifest with atrial fibrillation or flutter; therefore, obtain thyroid function tests. Hyperthyroidism is a rare cause of atrial flutter and should be excluded with blood testing.
  • Serum electrolytes and pulmonary function tests may be indicated based on the history.
  • Electrocardiography is essential in making the diagnosis.
    • The common form of type I atrial flutter has sawtooth flutter (F) waves, best seen in leads II, III, and aVF, with atrial rates of 240-340 bpm and without an isoelectric interval between these F waves.
    • The ventricular response may be regular or irregular.
    • The ventricular rate is a fixed mathematical relationship of flutter waves and the resulting QRS complexes.
    • Variable AV conduction can also be seen (commonly present with 2:1 or 3:1 AV conduction). With 1:1 AV conduction, hemodynamic collapse may occur.
    • Morphology of the flutter wave can predict findings in the electrophysiology laboratory. A negative flutter wave in the inferior limb leads and a positive flutter wave in V1 are highly predictive of a counterclockwise circuit; however, with positive flutter waves in the inferior limb leads and negative flutter waves in V1, differentiating between clockwise type I atrial flutter and atypical forms of non–isthmus-dependent intra-atrial reentry is difficult.

    • Twelve-lead ECG of type I atrial flutter. Note ne...

      Twelve-lead ECG of type I atrial flutter. Note negative sawtooth pattern of flutter waves in leads II, III, and aVF.

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      Twelve-lead ECG of type I atrial flutter. Note ne...

      Twelve-lead ECG of type I atrial flutter. Note negative sawtooth pattern of flutter waves in leads II, III, and aVF.

Imaging Studies

  • Transthoracic echocardiography should be performed to evaluate for structural abnormalities and left ventricular systolic function. It also can detect valvular abnormalities, left ventricular hypertrophy, and pericardial disease.
  • Transesophageal echocardiography is the preferred technique to detect thrombus in the left atrium.
  • Chest radiograph may be useful in evaluation of lung disease and the pulmonary vasculature.

Procedures

See Medical Care for information regarding radiofrequency ablation and electrical cardioversion.

More on Atrial Flutter

Overview: Atrial Flutter
Differential Diagnoses & Workup: Atrial Flutter
Treatment & Medication: Atrial Flutter
Follow-up: Atrial Flutter
Multimedia: Atrial Flutter
References
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References

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Further Reading

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Keywords

atrial flutter, atrial flutter treatment, arrhythmia, atrial fibrillation, supraventricular tachycardia, SVT, congestive heart failure, CHF, ventricular tachycardia, VT, ventricular fibrillation, VF, coronary artery disease, CAD, thromboembolic stroke, percutaneous catheter-based techniques, congenital cardiac anomalies, hypertensive heart disease, chronic obstructive pulmonary disease, COPD, thromboembolic complications, cardiomyopathy, hypoxia, thyrotoxicosis, pheochromocytoma

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Contributor Information and Disclosures

Author

Lawrence Rosenthal, MD, PhD, Associate Professor of Medicine, Director, Section of Cardiac Electrophysiology and Pacing, Fellowship Director of Clinical Cardiac Electrophysiology, Department of Internal Medicine, Division of Cardiovascular Medicine, University of Massachusetts Memorial Medical Center
Lawrence Rosenthal, MD, PhD is a member of the following medical societies: American College of Cardiology, American Heart Association, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Cynthia Anne Ennis, DO, Electrophysiology Fellow, University of Massachusetts Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Alan D Forker, MD, Professor of Medicine, Program Director of Cardiovascular Fellowship, University of Missouri at Kansas City School of Medicine; Director, Outpatient Lipid Diabetes Research Center, MidAmerica Heart Institute of St Luke's Hospital
Alan D Forker, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, American Society of Hypertension, and Phi Beta Kappa
Disclosure: Research Grant Grant/research funds Hospital contracts to do research; I am a hospital employee with no personal profit; Speakers Bureau Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Brian Olshansky, MD, Professor of Medicine, Department of Internal Medicine, University of Iowa College of Medicine
Brian Olshansky, MD is a member of the following medical societies: American Autonomic Society, American College of Cardiology, American College of Chest Physicians, American College of Physicians, American College of Sports Medicine, American Federation for Clinical Research, American Heart Association, Cardiac Electrophysiology Society, Heart Rhythm Society, and New York Academy of Sciences
Disclosure: Guidant/Boston Scientific Honoraria Speaking and teaching; Medtronic Honoraria Speaking and teaching; Guidant/Boston Scientific Consulting fee Consulting; Reliant Grant/research funds Other; Novartis Honoraria Speaking and teaching; Novartis Consulting fee Consulting

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Jeffrey N Rottman, MD, Professor of Medicine and Pharmacology, Director, Clinical Cardiac Electrophysiology Fellowship Program, Vanderbilt University School of Medicine; Chief, Department of Cardiology, Nashville Veterans Affairs Medical Center
Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association and North American Society of Pacing and Electrophysiology (NASPE)
Disclosure: Nothing to disclose.

 
 
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