eMedicine Specialties > Emergency Medicine > Cardiovascular

Atrial Flutter: Differential Diagnoses & Workup

Author: Pierre Borczuk, MD, Assistant Professor of Medicine, Harvard Medical School, Associate in Emergency Medicine, Massachusetts General Hospital
Contributor Information and Disclosures

Updated: Jul 2, 2009

Differential Diagnoses

Atrial Fibrillation

Other Problems to Be Considered

Narrow complex tachyarrhythmias
Wide complex tachyarrhythmias

Workup

Laboratory Studies

  • Obtain thyroid function studies.
  • Obtain serum electrolyte and digoxin levels if appropriate.
  • Obtain CBC if anemia is suspected or a history of recent or current blood loss is associated with presenting symptoms.
  • Consider obtaining blood gas measurements in patients with hypoxia or carbon monoxide intoxication. Also, seek a history of stimulant drug usage (eg, ginseng, cocaine, ephedra, methamphetamine).

Imaging Studies

  • Chest radiographic findings are usually normal in those with atrial flutter. Look for radiographic evidence of pulmonary edema in subacute cases.

Other Tests

  • Electrocardiography (ECG)
    • Atrial rate during typical (ie, type I) atrial flutter is usually 250-350 beats per minute, although class IA and IC antiarrhythmic drugs and amiodarone can reduce the rate to approximately 200 beats per minute. If this occurs, the ventricles can respond in a 1:1 fashion to the slower atrial rate.
    • Atrial rate ordinarily is about 300 beats per minute. In untreated patients, the ventricular rate is half the atrial rate (ie, 150 beats per minute). A significantly slower ventricular rate in the absence of drugs suggests abnormal AV conduction.
    • Atrial flutter can conduct to the ventricle in a 1:1 fashion, producing a ventricular rate of 300 beats per minute in children, in patients with the pre-excitation syndrome, in those whose AV nodes conduct rapidly, and occasionally in patients with hyperthyroidism.
    • The rate in atypical (ie, type II) flutter is 350-450 beats per minute. Re-entry within the right atrial (tricuspid annulus) is responsible for most cases of atrial flutter.
    • In cases of typical atrial flutter, ECG reveals identically recurring regular sawtooth flutter waves (see Media file 1) and evidence of continual electrical activity.

Type I atrial flutter unmasked by adenosine (Aden...

Type I atrial flutter unmasked by adenosine (Adenocard).

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Type I atrial flutter unmasked by adenosine (Aden...

Type I atrial flutter unmasked by adenosine (Adenocard).


    • Flutter waves are often visualized best in leads II, III, aVF, or V1. The flutter waves for typical (type I) atrial flutter are inverted (negative) in these leads because of a counterclockwise re-entrant pathway. Sometimes, they are upright (positive) when the re-entrant loop is clockwise. Flutter waves (particularly 2:1) can deform the ST complex in such a manner as to mimic an ischemic injury pattern on the 12-lead ECG.
    • Flutter and fibrillation often coexist with alternating patterns (ie, fib-flutter, flitter) in the same tracing.
  • Transthoracic echocardiography: A transthoracic echocardiogram is the preferred modality for evaluating atrial flutter. It can evaluate right and left atrial size, as well as the size and function of the right and left ventricles, which assists in diagnosing valvular heart disease, left ventricular hypertrophy (LVH), and pericardial disease. Transthoracic echocardiogram has low sensitivity for intra-atrial thrombi. 
  • Exercise testing: Exercise testing can be utilized to identify exercise-induced atrial fibrillation and to evaluate ischemic heart disease.
  • Holter monitoring: A Holter monitor can be used to help identify arrhythmias in patients with nonspecific symptoms, identify triggers, and detect associated atrial arrhythmias.

More on Atrial Flutter

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

  1. Suda K, Matsumura M, Hayashi Y. Myotonic dystrophy presenting as atrial flutter in childhood. Cardiol Young. Feb 2004;14(1):89-92. [Medline].

  2. Sassone B, Leone O, Martinelli GN, Di Pasquale G. Acute myocardial infarction after radiofrequency catheter ablation of typical atrial flutter: histopathological findings and etiopathogenetic hypothesis. Ital Heart J. May 2004;5(5):403-7. [Medline].

  3. Braunwald E. Heart disease: A Textbook of Cardiovascular Medicine. 5th ed. Philadelphia, Pa: WB Saunders Co; 1997:1997:641-656.

  4. Galve E, Rius T, Ballester R, et al. Intravenous amiodarone in treatment of recent-onset atrial fibrillation: results of a randomized, controlled study. J Am Coll Cardiol. Apr 1996;27(5):1079-82. [Medline].

  5. Goodacre S, Irons R. ABC of clinical electrocardiography: Atrial arrhythmias. BMJ. Mar 9 2002;324(7337):594-7. [Medline].

  6. Gronefeld GC, Wegener F, Israel CW, Teupe C, Hohnloser SH. Thromboembolic risk of patients referred for radiofrequency catheter ablation of typical atrial flutter without prior appropriate anticoagulation therapy. Pacing Clin Electrophysiol. Jan 2003;26(1 Pt 2):323-7. [Medline].

  7. Niebauer MJ, Chung MK. Management of atrial flutter. Cardiol Rev. Sep-Oct 2001;9(5):253-8. [Medline].

  8. Perry JC, Fenrich AL, Hulse JE, Triedman JK, Friedman RA, Lamberti JJ. Pediatric use of intravenous amiodarone: efficacy and safety in critically ill patients from a multicenter protocol. J Am Coll Cardiol. Apr 1996;27(5):1246-50. [Medline].

  9. Pritchett EL. Management of atrial fibrillation. N Engl J Med. May 7 1992;326(19):1264-71. [Medline].

  10. Prystowsky EN, Benson DW Jr, Fuster V, et al. Management of patients with atrial fibrillation. A Statement for Healthcare Professionals. From the Subcommittee on Electrocardiography and Electrophysiology, American Heart Association. Circulation. Mar 15 1996;93(6):1262-77. [Medline].

  11. Sawhney NS, Feld GK. Diagnosis and management of typical atrial flutter. Med Clin North Am. Jan 2008;92(1):65-85, x. [Medline].

  12. Seidl K, Rameken M, Siemon G. Atrial flutter and thromboembolism risk. Cardiol Rev. 1999;16(12):25-28.

  13. Vidaillet H, Granada JF, Chyou PH, et al. A population-based study of mortality among patients with atrial fibrillation or flutter. Am J Med. Oct 1 2002;113(5):365-70. [Medline].

  14. Waldo AL. Treatment of atrial flutter. Heart. Aug 2000;84(2):227-32. [Medline].

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Further Reading

Clinical guidelines

ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation). European Heart Rhythm Association, Heart Rhythm Society, Zipes DP, Camm AJ, Borggrefe M, et al, American College of Cardiology, American Heart Association Task Force, European Society of Cardiology Committee for Practice Guidelines. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society [trunc]. J Am Coll Cardiol 2006 Sep5;48(5):e247-346. [1085 references] PubMed

Antithrombotic therapy in atrial fibrillation. American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Singer DE, Albers GW, Dalen JE, Fang MC, Go AS, Halperin JL, Lip GY, Manning WJ. Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008 Jun;133(6 Suppl):546S-92S. [281 references] PubMed

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Keywords

atrial flutter, heart flutter, auricular flutter, catheter ablation, atrial flutter treatment, atrial flutter causes, atrial flutter symptoms, atrial fibrillation, bradyarrhythmia, tachyarrhythmia, arrhythmia, heart disease, acute myocardial infarction, AMI, congestive heart disease, CHD, coronary artery disease, CAD, cardiovascular disease, heart attack, rhythm disturbance, palpitations, fatigue, poor exercise tolerance, dyspnea, angina, syncope, rhythm disturbance of the atria, congestive heart failure, CHF, peripheral embolization, left ventricle dysfunction, long-standing hypertension, valvular heart disease, rheumatic heart disease, left ventricular hypertrophy, diabetes, depressed left ventricular function, myotonic dystrophy, postoperative revascularization, digitalis toxicity, pulmonary embolism

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Contributor Information and Disclosures

Author

Pierre Borczuk, MD, Assistant Professor of Medicine, Harvard Medical School, Associate in Emergency Medicine, Massachusetts General Hospital
Pierre Borczuk, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Edward Bessman, MD, Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University
Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Gary Setnik, MD, Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School
Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD, Assistant Professor, Department of Medicine, Division of Emergency Medicine, Harvard Medical School; Associate-Chief, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Schering  Honoraria Speaking and teaching

 
 
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