Background

Atrial flutter is an abnormal heart rhythm. It is also known as an arrhythmia. It affects the atria and it beat rapidly and a fasten heart rate. Symptoms of atrial flutter are like palpitations, chest discomfort, shortness of breath, fatigue, feeling dizzy or fainting. If it is left untreated, it leads to the conditions like reduced heart efficiency and increased risk of the blood clots. This can cause he stroke and other health issues.

Epidemiology

Atrial flutter is less common than atrial fibrillation (AF). Sometimes it occurs alongside. It occurs at the age of above 60 years. It occurs less in young people. It occurs when people have structural heart disease or risk factors. Males are at high risk of the atrial flutter than females. Recurrence may differ from individuals and by gender.

Anatomy

Pathophysiology

This disease occurs because of the re entry of the circuit in the atria. This forms the anatomical or functional barriers. This allows the electrical impulses to circulate continuously in a circular pattern. Atrial flutter keeps a more regular rhythm than the atrial fibrillation. Between the atria and ventricles, there AV node is present and works as a gatekeeper. It blocks the rapid atrial impulses and slow down the ventricular rate. This fast atrial rhythm can have hemodynamic effects. Atria contracts more strongly and ineffectively. It compromises the ability to fill the ventricles. This can lead to symptoms like palpitations, shortness of breath, and fatigue.

Etiology

This disease occurs because of the re entry of the circuit in the atria. This forms the anatomical or functional barriers. This allows the electrical impulses to circulate continuously in a circular pattern. Atrial flutter keeps a more regular rhythm than the atrial fibrillation. Between the atria and ventricles, there AV node is present and works as a gatekeeper. It blocks the rapid atrial impulses and slow down the ventricular rate. This fast atrial rhythm can have hemodynamic effects. Atria contracts more strongly and ineffectively. It compromises the ability to fill the ventricles. This can lead to symptoms like palpitations, shortness of breath, and fatigue.

Genetics

Prognostic Factors

Patients with catheter ablation in atrial flutter have a related and favourable prognosis. It contains the low recurrence rate. Untreated atrial flutter can lead to the tachycardia induced cardiomyopathy. It is a condition which lead to the heart failure decompensation and repeated hospitalization.

Clinical History

Identification the reasons or factors that can worse the atrial flutter can be useful. These includes factors like physical exertion, emotional stress, medicines or specific conditions. The other factors which are also taken into considered like history of cardiovascular diseases, structural heart defects, heart surgery, heart valve disease, lung disease, thyroid disease, diabetes, lifestyle changes like smoking, alcohol consumption and recreational drug. To assess the diagnose and evaluate cardiac function, diagnosis tests like ECGs, echocardiograms, stress tests or Holter monitoring.

Physical Examination

Atrial flutter is a disease caused by a rapid and regular atrial rhythm. An irregular ventricular response led to an irregular pulse during examination. Auscultation can detect abnormal heart sounds. This includes the pulse deficit which is caused by the missing ventricular response. If atrial flutter can cause the heart failure then it leads to the overload of the fluid and congestion. This will cause the increased jugular venous pressure, pulmonary crackles, peripheral edema and hepatomegaly. Atrial flutter alone cannot cause major changes in the blood pressure but with the other conditions like cardiovascular disease or complexities will contribute to the abnormalities. Other diseases include the structural heart disease, hyperthyroidism or embolic phenomena.

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

• Atrial Tachycardia
• Atrial Fibrillation
• Multifocal Atrial Tachycardia

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Rhythm Control

The main focus to manage the atrial flutter is to achieve and maintain the sinus rhythm. If it remains, it leads to the chronic remodelling of the atrial tissue. Different methods can be used to restore the sinus rhythm are like electrical cardioversion, pharmacological cardioversion and catheter ablation. If the patient is unstable then pharmacological cardioversion with antiarrhythmic drugs is sued. In newly diagnosed patients, anticoagulation therapy is used to reduce the risk of the blood clot. For the stable patient, electrical cardioversion is used.

Rate Control

Atrioventricular nodal agents like calcium channel blockers or beta blockers are used to control the rate. Digoxin is used with caution because of the side effects and toxicity. Combinations of these is the best management. To achieve the sufficient rate control is challenging and difficult because arrhythmia occur at the same rate. The targeted heart rate for rate control is below 110 beats per minute.

Efficacy in Permanent Atrial Fibrillation:

A study has compared the strict heart rate control (<80 bpm) with lenient control (<110 bpm) in patients with atrial fibrillation and atrial flutter.  The results indicates that the strict heart rate control is unnecessary. Lenient control leads to less side effects, polypharmacy. If the patients are intolerance to the medicines or have major bradycardia, catheter is used as an alternative.

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

1-use-of-a-non-pharmacological-approach-for-treating-atrial-flutter

• Electrical cardioversion: It is used to restore the regular electric shock, heart rhythm. It administers during the treatment. It effectively converts the atrial flutter to the normal sinus rhythm.
• Catheter ablation: It is minimally invasive technique. The aberrant electrical channels which cause atrial flutter are destroyed or isolated. It id done by the radiofrequency radiation or cryotherapy.

Lifestyle Modifications:

• Stress management: Stress can be managed by the meditation and yoga. It improves overall heath.
• Regular exercise: Regular physical exercise can improve the cardiovascular health.

Dietary Changes:

• Healthy eating: A healthy diet includes whole grains, fruits and lean meats can improves the cardiovascular health.

Weight Management:

• Maintaining a healthy weight: Weight management by the regular exercise and healthy diet can decrease the risk and severity of arrhythmias.

Alcohol and Caffeine Moderation:

• Limiting alcohol and caffeine intake: Moderate or less consumption of caffeine and alcohol is recommended.

Sleep Hygiene:

• Ensuring adequate sleep: Good sleep hygiene is beneficial for the good cardiovascular health.

Monitoring and Identifying Triggers:

• Keeping a symptom diary: Identify what triggers the atrial flutter and avoid or manage them by non-pharmacological approach.

Role of Class IC antidysrhythmic in the treatment of Atrial flutter

Class IC antiarrhythmic drugs helps to control and stabilize the heart rhythm. Class IC antiarrhythmics blocks the sodium channels in cardiac cells and lead to decrease in the conduction velocity. It increases the refractory time.

• Flecainide: It is a class IC antiarrhythmic drug. It helps to control and stabilize the heart rhythm. It blocks the sodium channels in cardiac cells and lead to decrease in the conduction velocity. It increases the refractory time. It is recommended to the patient who have not structural heart disease and have not history of heart attack. Regular monitoring by electrocardiograms (ECGs) is necessary.
• Propafenone: It is a class IC antiarrhythmic drug. It helps to control and stabilize the heart rhythm. It blocks the sodium channels in cardiac cells and lead to decrease in the conduction velocity. It is effective to convert the atrial flutter to normal sinus rhythm. It is recommended to the patient who have not structural heart disease and have not history of heart attack. Regular monitoring by electrocardiograms (ECGs) is necessary.

Role of Class III antidysrhythmic in the treatment of Atrial flutter

Class III antiarrhythmic drugs helps to control and stabilize the heart rhythm. Class IC antiarrhythmics blocks the potassium channels in cardiac cells and lead to decrease in the conduction velocity. It increases the refractory time. It is effective to convert the atrial flutter to normal sinus rhythm. It is recommended when other antiarrhythmic medications failed or contraindicated to others.

• Dronedarone: It is a derivative of amiodarone and also belongs to Class III antiarrhythmics. It is used to maintain normal sinus rhythm. It prevents recurrence of atrial flutter. It is often considered as an alternative to amiodarone. It is generally used in patients with a lower risk of side effects compared to amiodarone. Monitoring liver function and pulmonary issues is necessary.
• Sotalol: It is a non-selective beta-blocker with Class III antiarrhythmic properties. It blocks beta-adrenergic receptors and potassium channels. It increases the refractory time. It is recommended to the patient who have not structural heart disease.
• Ibutilide: It is a Class III antiarrhythmic agent. It is used for acute cardioversion of atrial flutter. It is effective to convert the atrial flutter to normal sinus rhythm.
• It is often used for acute cardioversion of atrial flutter. It is effective to convert the atrial flutter to normal sinus rhythm. Regular monitoring by electrocardiograms (ECGs) is necessary.
• Amiodarone: It increases the refractory time. Amiodarone reduces the premature impulses. It maintains the atrial flutter. It is effective to convert the atrial flutter to normal sinus rhythm.
• Dofetilide: Dofetilide action is similar o the amiodarone. It increases the refractory time. It prevents the re entry of the abnormal electrical signals. It is effective to convert the atrial flutter to normal sinus rhythm.

Role of Class IV antidysrhythmic in the treatment of Atrial flutter

Class IV antiarrhythmics blocks the calcium channels in cardiac cells. It inhibits the calcium influx during the cardiac action. It leads to decrease the contractility and conduction velocity of heart.

• Verapamil: It is a calcium channel blocker. It blocks the calcium channels in cardiac cells mainly in AV node. It controls the atrial flutter. It inhibits the calcium influx during the cardiac action. It leads to decrease the contractility and conduction velocity of heart. It also helps to manage the symptoms like palpitations, shortness of breath and fatigue.
• Diltiazem: It is a calcium channel blocker. It blocks the calcium channels in cardiac cells mainly in AV node. It controls the atrial flutter. It inhibits the calcium influx during the cardiac action. It leads to decrease the contractility and conduction velocity of heart. It also helps to improve the hemodynamics.

Role of Class V antidysrhythmic in the treatment of Atrial flutter

Class V antiarrhythmics include agents like adenosine and digoxin. It contains diverse mechanisms of action and are not easily categorized into other classes.

• Digoxin: Digoxin inhibits the sodium-potassium pump. It increases intracellular calcium levels and indirectly affects the cardiac contractility and conduction.

Role of Anticoagulants in the treatment of Atrial Flutter

Anticoagulants are also used to treat the atrial flutter. Types of anticoagulants are like vitamin K antagonists like warfarin and oral anticoagulants like dabigatran, rivaroxaban, apixaban, and edoxaban prevent the complications. The choice depends on the patient preference and renal function.

• Heparin: It is used as an initial anticoagulant. It prevents the formation of the blood clots. It administers intravenously. It is used before the procedures like cardioversion. It has a short term action. In the acute phase, it switches to the long term anticoagulant like warfarin or a direct oral anticoagulant (DOAC).
• Warfarin: It is a vitamin K antagonist and a traditional oral anticoagulant. It is used to prevent stroke in atrial flutter. It requires regular monitoring of the International Normalized Ratio (INR). The target INR may vary but falls between 2.0 and 3.0 for atrial fibrillation or atrial flutter.
• Dabigatran: It is a thrombin inhibitor and a direct oral anticoagulant (DOAC). It is taken orally. It does not require routine monitoring. The dosage is twice a day daily. Dabigatran is an alternative to warfarin.
• Apixaban: It is a factor Xa inhibitor and a direct oral anticoagulant (DOACs). Apixaban is effective to prevent stroke in atrial fibrillation. It is an alternative to warfarin for atrial flutter.

Use of Beta blockers in the treatment of Atrial flutter

Beta blockers are used to treat atrial flutter. It controls the heart rate and manage the symptoms. They block stress hormones and reduces heart rate and blood pressure. This helps to slow down electrical signals in the heart in the AV node. Beta blockers reduces the symptoms like palpitations, shortness of breath and fatigue.

Metoprolol: It is a commonly prescribed beta blocker. It blocks beta 1 receptors.

• Atenolol: It is used to manage of atrial flutter. It is selective for beta-1 receptors. It reduces the heart rate.
• Propranolol: It is a non-selective beta blocker. It blocks both beta-1 and beta-2 receptors. It controls the heart rate and blood pressure.
• Bisoprolol: It is a cardio selective beta blocker. It blocks beta-1 receptors. It is used for rate control in atrial flutter.

use-of-intervention-with-a-procedure-in-treating-atrial-flutter

• Catheter Ablation: This is the primary interventional procedure used to treat atrial flutter. During catheter ablation, a thin, flexible tube is guided to blood vessels to the heart. Once in place, the catheter delivers energy (such as radiofrequency or cryotherapy) to destroy or ablate the abnormal tissue causing the flutter. By disrupting the electrical pathways responsible for the abnormal rhythm, catheter ablation can effectively restore normal heart rhythm. 
• Electrical Cardioversion: In some cases, atrial flutter may be treated with electrical cardioversion. In order to restore the heart’s normal rhythm, a regulated electric shock is administered to the heart, usually while the patient is sedated. While electrical cardioversion can quickly terminate atrial flutter, its effects may be temporary, and maintenance therapy with medications or catheter ablation may be needed to prevent recurrence. 
• Implantable Devices: In certain situations, implantable devices such as implantable cardioverter-defibrillators (ICDs) or pacemakers may be used to manage atrial flutter. These devices can help regulate the heart’s rhythm and prevent dangerous arrhythmias. 
• Medications: While interventional procedures are often effective in treating atrial flutter, medications may also play a role in managing the symptoms and decreasing the risk of complications. Antiarrhythmic drugs, such as flecainide, propafenone, or sotalol, may be prescribed to help maintain normal heart rhythm after an interventional procedure or as a standalone treatment for those who are not candidates for or prefer to avoid invasive procedures. 
• Lifestyle Modifications: Lifestyle changes, such as avoiding triggers like caffeine or alcohol, managing stress, maintaining regular exercise,a healthy weight, and can also help manage atrial flutter and reduce the risk of recurrence. 

use-of-phases-in-managing-atrial-flutter

Acute Management:

• Symptom Relief: The main focus is to reduce the symptoms and stabilize the patient. Medicines can slow down the heart rate or control the rhythm.
• Electrical Cardioversion: If the patient is hemodynamically unstable or have severe symptoms then electrical cardioversion is used. It restores the normal heart rhythm.

Rhythm Control:

• Antiarrhythmic Medications: Drugs like flecainide, propafenone, amiodarone or sotalol is used to maintain normal sinus rhythm.
• Catheter Ablation: Catheter ablation is a definitive treatment. It destroys the abnormal electrical signals in the heart. This eliminate the flutter circuit and restores the normal heart rhythm.

Long-Term Management:

• Medications: Long term antiarrhythmic medications is used to prevent the recurrence of the atrial flutter.
• Implantable Devices: Implantable devices like pacemakers or implantable cardioverter-defibrillators (ICDs) are used to help regulate the heart rhythm and prevent arrhythmias.
• Lifestyle Modifications: Lifestyle changes like avoid triggers like caffeine, alcohol, stress, maintain a healthy weight, regular exercise and quit the smoke can help to manage atrial flutter and reduce the risk of recurrence.
• Follow-Up and Monitoring:
• Regular follow-up, adjustment of medications, and assess for the recurrence of symptoms or arrhythmias is important. Periodic cardiac monitoring like Holter monitoring or event monitoring is also important.

Medication

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References

Atrial flutter: ncbi.nlm.nih.