Atrial Flutter Clinical Presentation

Updated: Nov 18, 2019
  • Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jeffrey N Rottman, MD  more...
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Symptoms in patients with atrial flutter typically reflect decreased cardiac output as a result of the rapid ventricular rate. Typical symptoms include the following:

  • Palpitations
  • Fatigue or poor exercise tolerance
  • Mild dyspnea
  • Presyncope

Less common symptoms include angina, profound dyspnea, or syncope resulting from compromised left ventricular function. Thromboembolic events are possible with this arrhythmia. In addition, patients may have symptoms of the conditions that are causing the atrial flutter. These may be noncardiac (eg, hyperthyroidism or pulmonary disease) or cardiac.

The clinician should attempt to elicit information about factors that may have precipitated the episode of atrial flutter, including alcohol, as well as medical conditions (eg, pneumonia or acute myocardial infarction) and surgical procedures. An effort should also be made to elicit any history of using stimulant drugs (eg, ginseng, cocaine, ephedra, or methamphetamine).

Determining when the onset of symptoms occurred is critical, in that the duration of the episode affects management. For atrial flutter lasting longer than 48 hours, anticoagulation with warfarin or transesophageal echocardiography is required to rule out thrombus in the left atrium before cardioversion to sinus rhythm. In patients with a history of atrial flutter, the history should include precipitating causes and modes of termination of the arrhythmia.

Atrial flutter rhythm itself is unstable and usually reverts either to atrial fibrillation or to sinus rhythm. It would be unusual but certainly not impossible for a patient to remain in stable chronic atrial flutter. A history of preexcitation syndrome (Wolff-Parkinson-White) indicates a need for caution; these patients are at risk for 1:1 conduction of the flutter waves, which can cause ventricular fibrillation.

Patients with concurrently diagnosed new rapid atrial fibrillation or atrial flutter and new reduced left ventricular ejection fraction typically have heavy alcohol intake and a high rate prevalence of left atrial appendage thrombi. [10]


Physical Examination

The patient’s general appearance and vital signs are important for determining the urgency of restoring sinus rhythm. Thus, the initial cardiopulmonary evaluation and monitoring for signs of cardiac or pulmonary failure help guide initial management.

Pay careful attention to the heart rate, blood pressure, and oxygen saturation. Tachycardia may or may not be present, depending on the degree of atrioventricular (AV) block associated with the atrial flutter activity.

The heart rate is often approximately 150 beats/min because of a 2:1 AV block. (This depends on the atrial firing rate, which may be influenced by medications as well as by intrinsic cardiac factors.) The venous pulsations may be more rapid at the rate of the flutter. Because the AV block may be variable, the pulse may be regular or slightly irregular. Hypotension is possible, but normal blood pressure is more commonly observed.

Other elements of the physical examination are as follows:

  • Palpate the neck and thyroid gland for goiter
  • Evaluate the neck for jugular venous distention
  • Auscultate the lungs for rales or crackles
  • Auscultate the heart for extra heart sounds and murmurs
  • Palpate the point of maximum impulse on the chest wall
  • Assess the lower extremities for edema or impaired perfusion

If embolization has occurred from intermittent atrial flutter, findings are related to brain or peripheral vascular involvement. In addition to neurologic insult, other complications of atrial flutter may include the following:

  • Embolization (arterial)
  • Congestive heart failure
  • Severe bradycardia
  • Myocardial rate–related ischemia