eMedicine Specialties > Emergency Medicine > Cardiovascular

Atrial Flutter: Follow-up

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

Follow-up

Further Inpatient Care

  • Patients in atrial flutter (AFL) are at risk for thromboembolization and should be treated with oral anticoagulants in the same fashion as patients with atrial fibrillation.
  • Patients who undergone cardioversion will need to be on warfarin for 4 weeks with an INR goal in the 2-3 range.
  • Catheter ablation treatment
    • Typical or reverse typical atrial flutter has a 95% cure rate with radiofrequency ablation (RFA) techniques and is the long-term treatment of choice in patients with symptomatic atrial flutter.
    • In patients who have failed antiarrhythmic therapy or who have failed RFA and who are symptomatic, palliative therapy with AV-His Bundle ablation can eliminate rapid ventricular rates, but it does require a permanent pacemaker to be placed, as this procedure creates third-degree heart block.

Transfer

  • Transfer to a referral center may be indicated for patients who present to the emergency department (ED) with complications of atrial flutter, including the following:
    • Bradycardia (eg, from sick sinus syndrome) requiring pacemaker therapy
    • Unresponsive rate despite adequate medical therapy; after electrical cardioversion, referral for electrophysiologic ablation may be appropriate. These patients generally are transferred from one inpatient facility to another.
    • Embolic complications requiring surgical therapy (ie, arterial embolization), cerebrovascular accident (CVA), AF, or atrial flutter requiring neurointensive care

Complications

  • Complications of atrial flutter may include the following:
    • Stroke
    • Embolization (arterial)
    • Congestive heart failure (CHF)
    • Severe bradycardia
    • Myocardial rate-related ischemia

Prognosis

  • With atrial fibrillation (AF) and atrial flutter, the relative risk for development of stroke is 4.1% compared with control subjects.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Some patients with atrial flutter or atrial fibrillation and pre-excitation syndrome (Wolff-Parkinson-White syndrome) are at risk for 1:1 conduction via their accessory pathway when nodal agents preferentially block the AV node. This can cause ventricular fibrillation.
  • Watch for development of severe bradycardia during treatment. This may cause severe hypotension and death if not carefully monitored.
  • Rarely, atrial fibrillation (AF) or atrial flutter may be due to pericardial disease or effusion or carbon monoxide intoxication. Keep these rare events in mind when dealing with the unusual case of a patient who does not respond to standard therapy.
  • While radiofrequency (RF) ablation is beyond the domain of the ED physician, complications of this procedure are reported in the literature. The physician must be knowledgeable of these complications when treatment options are proposed to the patient and family members. Of interest is a report by Sassone et al of thermal-related right coronary artery damage secondary to RF therapy in a patient with resultant myocardial infarction.2
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Alan D Clark, MD †, Jeffrey Lazar, MD, and Vivek Parwani, MD, to the development and writing of this article.



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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