Diagnostic Considerations

Coarse atrial fibrillation may mimic atrial flutter over limited electrocardiogram (ECG) strips. Prolonged recordings will uncover an irregular rate and variation in P wave morphology (as compared to a regular rate and P wave morphology with atrial flutter). The distinction between atrial flutter and atrial tachycardia is generally arbitrarily based on the atrial rate, and does not mechanistically distinguish these rhythms.

The ECG should be reviewed for the following:

Artifact from tremor
Atrial tachycardia with atrioventricular block
Atrial tachycardia, multifocal
Narrow-complex tachyarrhythmias
Wide-complex tachyarrhythmias

Differential Diagnoses

Workup

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Media Gallery

Anatomy of classic counterclockwise atrial flutter. This image demonstrates an oblique view of the right atrium and shows some crucial structures. The isthmus of tissue responsible for atrial flutter is seen anterior to the coronary sinus (CS) orifice. The eustachian ridge is part of the crista terminalis that separates the roughened part of the right atrium from the smooth septal part of the right atrium. IVC = inferior vena cava; SVC = superior vena cava.
Typical counterclockwise atrial flutter. This 3-dimensional electroanatomic map of a tricuspid valve and right atrium shows the activation pattern displayed in color format. Red is early and blue is late, relative to a fixed point in time. Activation travels in counterclockwise direction.
A 12-Lead electrocardiogram of typical atrial flutter. Note the negative sawtooth pattern of the flutter waves in leads II, III, and aVF.
Electrocardiogram of atypical left atrial flutter.
3-Dimensional electroanatomic map of typical atrial flutter. Colors progress from blue to red to white and represent the relative conduction time in the right atrium (early to late). An ablation line (red dots) has been created on the tricuspid ridge extending to the inferior vena cava. This ablation line interrupts the flutter circuit. CSO = coronary sinus os; IVC = inferior vena cava; RAA = right atrial appendage; TV = tricuspid valve annulus.
Rhythm strips demonstrating typical atrial flutter unmasked by adenosine (Adenocard).

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Table. Medications, Strategies, and Techniques Specified or Not Mentioned in the 2019 Guidelines

Table. Medications, Strategies, and Techniques Specified or Not Mentioned in the 2019 Guidelines

Type of Tachycardia	Treatment (Grade)	Not Mentioned in 2019 Guidelines
Narrow QRS tachycardias	Verapamil and diltiazem; beta-blockers (now all are grade IIa)	Amiodarone, digoxin
Wide QRS tachycardias	Procainamide, adenosine (both grade IIa); amiodarone (IIb)	Sotalol, lidocaine
Inappropriate sinus tachycardia	Beta-blockers (IIa)	Verapamil/diltiazem, catheter ablation
Postural orthostatic tachycardia syndrome	Salt and fluid intake (IIb)	Head-up tilt sleep, compression stockings, selective beta-blockers, fludrocortisone, clonidine, methylphenidate, fluoxetine, erythropoietin, ergotaminel octreotide, phenobarbitone
Focal atrial tachycardia	Acute: beta-blockers (IIa); flecainide/propafenone, amiodarone (IIb)	Acute: procainamide, sotalol, digoxin
Focal atrial tachycardia	Chronic: beta-blockers; verapamil and diltiazem (all IIa)	Chronic: amiodarone, sotalol, disopyramide
Atrial flutter	Acute: ibutilide (I); verapamil and diltiazem, beta-blockers (all IIa); atrial or transesophageal pacing (IIb); flecainide/propafenone (III)	Acute: digitalis
Atrial flutter	Chronic: —	Chronic: dofetilide, sotalol, flecainide, propafenone, procainamide, quinidine, disopyramide
Atrioventricular nodal re-entrant tachycardia (AVNRT)	Acute: —	Acute: amiodarone, sotalol, flecainide, propafenone
Atrioventricular nodal re-entrant tachycardia (AVNRT)	Chronic: verapamil and diltiazem; beta-blockers (all IIa)	Chronic: amiodarone, sotalol, flecainide, propafenone, “pill-in-the-pocket” approach
Atrioventricular re-entrant tachycardia (AVRT)	Beta-blockers (IIa); flecainide/propafenone (IIb)	Amiodarone, sotalol, “pill-in-the-pocket” approach
SVT in pregnancy	Verapamil (IIa); catheter ablation (IIa when fluoroless ablation is available)	Sotalol, propafenone, quinidine, procainamide
Adapted from Brugada J, Katritsis DG, Arbelo E, et al, for the ESC Scientific Document Group. 2019 ESC Guidelines for the management of patients with supraventricular tachycardia. The Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J. 2019 Aug 31;ehz467. https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehz467/5556821

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Atrial Flutter Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

Tables

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