Atrial Flutter

Atrial flutter is a health condition (arrhythmia) where the atria of the heart as an electrical problem (a re-entry loop) that causes the atria to beat at a rapid rate of about 242 - 360 beats per minute (bpm).

• Atrial flutter is a condition where the atria of the heart rapidly and regularly beat due to an anomaly in the heart's electrical system that usually results in tachycardia.
• It produces feelings like near-fainting, rapid heartbeats (palpitations), mild shortness of breath, and fatigue.
• This type of arrhythmia can be dangerous because complications can easily develop.
• Atrial fibrillation lasts for variable periods ranging from intermittent short time periods to constant rapid heartbeats.
• Atrial flutter and atrial fibrillation (AFib) are closely related. Flutter produces regular tachycardia while fibrillation produces irregular tachycardia.
• Certain triggers may cause arrhythmia; however, the triggers result in a reentry loop that causes the heart's electrical system to produce rapid, regular atrial contractions.
• Risks for getting this heart condition include a number of medical problems, advanced age, and poor personal habits such as unhealthy eating habits and drinking too much alcohol. 
• Atrial flutter is not the same as a stroke or a heart attack.
• Although there are many tests to evaluate atrial flutter, the most common diagnostic test is an electrocardiogram (ECG/EKG).
• Antiarrhythmics, beta-blockers, and anticoagulants are the three general types of drugs used to treat and manage this type of heart disease.
• Medical procedures to treat and manage flutter may include Valsalva procedures, cardioversion, cardiac ablation, and medication for the prevention of clot formation.
• Your risk of developing atrial flutter can be reduced by avoiding drinking excessive alcohol, eating a healthy diet, and appropriate care for any medical condition.
• The prognosis for patients with atrial flutter that get ablation treatment is excellent. Those who have additional medical problems and respond to treatments poorly have a worse prognosis and likely a shorter lifespan.
• Doctors that treat the disease may include primary care physicians, emergency medicine, cardiologists, and electrophysiologists.

ECG Strip (Electrocardiogram, EKG) of Sawtooth Pattern of Atrial Flutter

Atrial flutter is a health condition (arrhythmia) where the atria of the heart as an electrical problem (a re-entry loop) that causes the atria to beat at a rapid rate of about 242 - 360 beats per minute (bpm).

It is the second most common tachyarrhythmia, with atrial fibrillation (AFib) being the most common. Although usually flutter waves are regular and appear as "sawtooth" P waves in ECG's (typical atrial flutter); occasionally electrical conduction blocks can occur and produce 2:1, 3:1, or 4:1 waves or even appear as irregular bpm's resembling irregular arrhythmia. Infrequently, atrial flutter may be seen with bradycardia (an abnormal heart rhythm that is slow) when the heart ventricles do not receive most of the atrial flutter P waves and thus do not mimic the atrial rate.

Although a few people have no symptoms, common clinical symptoms of this arrhythmia are as follows:

1. Palpitations (feeling of heart beating or pounding)
2. Fatigue
3. Shortness of breath (usually mild)
4. Pre-syncope (feeling like you going to faint)
5. Lightheadedness
6. Blurry vision

Less common but more serious symptoms of this flutter arrhythmia include chest pain, more severe shortness of breath, and fainting. These symptoms suggest that your health is being compromised.

Although no one knows for sure what triggers or causes atrial flutter, atrial flutter is caused by a disruption in the normal electrical signals that control the heartbeat. In a healthy heart, the electrical signals that regulate the heartbeat originate in the sinoatrial (SA) node, a small cluster of cells in the right atrium.  The signals then travel through the heart in a coordinated manner, causing the atria and ventricles to contract in a synchronized fashion.

In individuals with these risk factors, some injury probably occurs to alter the healthy electrical pacemaker in the heart atrium that allows a reentry loop for electrical signals to follow. The sinus node sends out an electric signal, but travels along the continuous loop in atrial flutter causing the atria of the heart to contract rapidly, usually with the atria contracting faster than the ventricles although some individuals with heart disease can have about a 1:1 conduction that results in a heartbeat of about 250 – 300 bpm.

There are several factors that can increase the risk of developing atrial flutter, including:

• Heart disease: Structural abnormalities or damage to the heart, such as coronary artery disease, valve disease, or prior heart surgery, can increase the risk of atrial flutter.
• Age: Atrial flutter is more common in older adults, particularly those over age 60.
• High blood pressure: Hypertension can increase the risk of atrial flutter by placing additional strain on the heart.
• Lung disease: Certain lung conditions, such as chronic obstructive pulmonary disease (COPD) or pulmonary embolism, can increase the risk of atrial flutter.
• Alcohol or drug use: Excessive alcohol or drug use can damage the heart and increase the risk of atrial flutter.
• Genetics: A family history of cardiac arrhythmia may increase the risk of developing atrial flutter.

Atrial flutter arrhythmias can be dangerous to your health because of complications caused by the heart condition. Atrial flutter can be a serious medical condition, particularly if it is left untreated or if it causes other complications. While some people with atrial flutter may not experience any symptoms, others may experience symptoms such as heart palpitations, shortness of breath, chest pain, fatigue, and dizziness.

Some typical and atypical atrial flutter complications include:

• Tachycardia or rapid heartbeat (blood may not be pumped adequately resulting in decreased function or failure of various organs, especially the brain and heart muscle)
• Low blood pressure (hypotension)
• Thromboembolism
• Stroke: Atrial flutter can increase the risk of a blood clot forming in the heart, which can then travel to the brain and cause a stroke.
• Cardiomyopathy
• Chronic atrial fibrillation

The seriousness of atrial flutter depends on the specific individual and their overall health. In many cases, atrial flutter can be managed effectively with medications or procedures such as catheter ablation or electrical cardioversion. However, it's important to seek medical attention if you experience any symptoms of atrial flutter or have any concerns about your heart health.

Atrial flutter or atrial fibrillation lasts for variable times. In some people, it can convert to normal sinus rhythm often within a week or so, or it can continue constantly for weeks or months. Some patients may have flutter waves that last less than a day, spontaneously terminate, but return irregularly, and are termed paroxysmal atrial flutter. Unfortunately, atrial flutter also can convert to another abnormal heart rhythm such as atrial fibrillation during the same period.

In general, the longer that atrial flutter persists, the greater the risk of complications such as blood clots or heart failure. It's important to seek medical attention if you experience any symptoms of atrial flutter or if you have concerns about your heart health.

There are many risk factors for this type of flutter. The following is a list of some of the more common risk factors:

• High blood pressure
• Obesity
• Diabetes
• Heart failure
• Ischemic heart disease and/or a previous heart attack
• Serious acute illnesses
• Heavy alcohol intake and/or binge drinking
• Advanced age
• Hyperthyroidism
• Chronic lung disease
• Recent surgery
• Congenital heart disease

Atrial flutter and atrial fibrillation (AFib) are both types of cardiac arrhythmia that occur in the upper chambers of the heart, called the atria. While both conditions can cause symptoms such as heart palpitations, shortness of breath, and fatigue, they differ in several ways.

The main difference between atrial flutter and atrial fibrillation (AFib) is that in atrial flutter, the rapid heartbeat (typically between 250 and 350 beats per minute) is regular while in atrial fibrillation the heartbeat is irregular with no consistent pattern.  

While both conditions can increase the risk of blood clots and stroke, AFib is generally considered to be more concerning because of the higher risk of complications.

However, the other symptoms mentioned above are very similar. Moreover, diagnosis and treatment procedures also are similar if not exactly the same. For example, treatment guidelines for atrial fibrillation and atrial flutter by the American Heart Association are the same.

Atrial flutter is not the same as a stroke or heart attack. It is an abnormal heartbeat that usually is regular and faster than normal. Although atrial flutter and atrial fibrillation can lead to a stroke or heart attack, it is neither. 

Atrial flutter is an abnormal heart rhythm that occurs when the electrical signals in the atria (the upper chambers of the heart) become disorganized and rapid, causing the atria to contract too quickly and inefficiently. This can lead to symptoms such as heart palpitations, shortness of breath, and fatigue, and can increase the risk of other complications such as blood clots and heart failure.

A stroke is defined as a sudden disabling attack or loss of consciousness caused by an interruption in the flow of blood to the brain. Atrial flutter can increase the risk of blood clots forming in the heart, which can then travel to the brain and cause a stroke.

A heart attack (myocardial infarction) is a sudden and sometimes fatal occurrence usually due to coronary thrombosis, resulting in the death of part of the heart's muscle. While atrial flutter can increase the risk of developing other cardiac conditions such as heart failure, it is not typically associated with an increased risk of a heart attack.

Differences between ECG wave strip patterns

Atrial flutter is diagnosed by your medical history, history of symptoms, and physical exam. Electrocardiography (ECG or EKG) frequently makes the diagnosis by showing saw tooth flutter waves in several (II, III, aVF, and/or V1) of the 12 ECG leads recorded, indicating atrial tachycardia of about 250 – 350 bpm.

Atrial flutter ECG sawtooth wave strip pattern

ECG Sawtooth Wave Strip Pattern of Atrial Flutter

Normal ECG wave pattern

Normal ECG Wave Strip Pattern

Other tests to diagnose atrial flutter

Other tests are useful to diagnose this tachycardia when flutter waves are obscured by the ventricular tachycardia. These tests and medical devices include vagal maneuvers, administration of IV adenosine, and when the flutter waves come and go intermittently. The Holter monitor may be used to identify the arrhythmia.

Other studies may be done to help evaluate a patient's atrial flutter. For example, transesophageal electrocardiography can evaluate the heart for the presence of a thrombus and transthoracic electrocardiography can image the internal parts of the heart using ultrasound. In addition, your doctor or other health care professional may order additional tests for underlying problems that may trigger symptoms.

There are three types of drugs used to treat atrial flutter.

Antiarrhythmics: slows or interferes with the electric signals that produce atrial flutter; examples are:

• propafenone (Rythmol)
• flecainide (Tambocor)
• amiodarone (Cordarone)
• dronedarone (Multaq)
• sotalol (Betapace)
• dofetilide (Tikosyn)
• diltiazem (Cardizem)
• verapamil (Calan)
• digoxin (Lanoxin)

Beta-Blockers: slow the heart's ventricular response to atrial signals by slowing the AV nodal conduction; examples are:

• metoprolol (Lopressor)
• esmolol (Brevibloc)
• atenolol (Tenormin)

Anticoagulants: used to prevent thromboembolic complications (blood clots); examples are:

• warfarin (Coumadin, Jantoven)
• heparin
• dabigatran (Pradaxa)
• apixaban (Eliquis)
• rivaroxaban (Xarelto)

The choice of medication(s) to use is based on your medical condition. These medications should be discussed with your doctor or other health care professional before you take them.

Although primary care physicians can treat a few individuals with uncomplicated atrial flutter, specialists usually are involved in patient care.

• Emergency medicine specialists and cardiologists are the main specialists that see and treat this type of arrhythmia.
• Cardiac electrophysiologists specialize in the diagnosis and treatment of the electrical activity of the heart.

The procedures used for the treatment and management of atrial flutter are varied; however, the goals are similar - the restoration of sinus rhythm, control of ventricular rate prevention of recurrent episodes, and prevention of thrombus formation - all with minimizing adverse effects from therapy.

In patients that are stable, vagal maneuvers such as holding your breath and bearing down (like having a bowel movement) may be effective. Other procedures may need to be considered depending on the individual patient's situation, for example, immediate electrical cardioversion is used for patients who have severe symptoms and are unstable. For patients that are stable but still have episodes of atrial flutter, radiofrequency ablation of the circular pathway in the heart can be done as an elective procedure. Other procedures or heart abnormalities may cause a few patients to need a pacemaker to control their heart rate.

Although some patients may recover completely and remain in a sinus rhythm, others may require additional therapy to prevent thromboembolic (blood clots) complications with anticoagulant medication.

Atrial flutter can be prevented or the risk of it decreased by reducing the factors that may trigger it. The simplest things to do to prevent it are:

• Get regular exercise and be active
• Eat a heart-healthy diet
• Avoid drinking too much alcohol and/or caffeine.
• Don't smoke
• Maintain a healthy weight

If you have underlying health conditions such as lung disease or diabetes, for example, appropriate treatment of these conditions will help decrease the risk or prevent atrial flutter. The ablation procedure may prevent subsequent occurrences of an abnormal heart rhythm like atrial fibrillation and an atrial rate seen in atrial flutter and restore relatively normal electrical heart health.

The prognosis and life expectancy for a person with atrial flutter depend on the patient's underlying condition.

• Those with complicated medical conditions and who respond poorly to drugs or procedures have a reduced prognosis.
• However, patients that undergo successful ablation have an excellent prognosis.

Although there is little or no data available on life expectancy with atrial flutter, data from the well-known Framingham heart study suggests that patients with atrial fibrillation, which is closely related to atrial flutter, have a shorter lifespan than normal control individuals although how much shorter is not clear. 

It's important to work closely with a healthcare professional to manage atrial flutter and any associated symptoms or complications. This may involve regular monitoring of heart rhythm, medication management, lifestyle changes, or procedures to correct the abnormal heart rhythm. With proper care and management, many people with atrial flutter are able to manage their condition effectively and enjoy a good quality of life.