Flutter, atrial

Atrial Clutter is rhythm disturbance associated with stmctural heart disease. Atrial Flutter is a form of atrial tachycardia that usually originates in the right atria (Fig. 6.23) and is usually paroxysmal, lasting several hours or days. Longer lasting or chronic flutter is rare. Atrial Flutter and Atrial Fibrillation are closely linked and can alternate in individuals. A prolonged Atrial Flutter often converts itself into Atrial Fibrillation. Flutter can be identified on the ECG by its classic sawtooth like appearance, seen best in lead II, III and aVF. As with Atrial Fibrillation there are no P waves, but instead prominent Flutter F waves (Fig. 6.24). 

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Reentry mechanism Intranodal (AV node) reentry Extranodal reentry Reentrant tachyarrhythmia Atrial flutter Atrial fibrillation Ventricular tachycardia Ventricular fibrillation Conduction B/ocks ... 

Dlgltoxin. Digitoxin is a cardiac glycoside obtained from Digitalis purpurea. Digitoxin is indicated in the treatment of atrial flutter, atrial fibrillation, and supraventricular tachycardia. Its electrophysiologic and adverse effects are similar to those described for digoxin (87). 

Newly developed class III drugs comprise dofetilide, a specific Ik, blocker, and ibutilide, which blocks IKl and activates the slow iNa- Both drugs lack hemodynamic side effects. These drugs are scheduled for the treatment of atrial fibrillation and atrial flutter. As with class HI drugs, they can induce torsade de pointes arrhythmia. 

The risk of atrial flutter is a 2 1 transmission to the ventricles generating a high ventricular rate. The therapeutic goal is to reduce transmission to 3 1 or 4 1 by administration of either (3-adrenoceptor antagonists, Ca2+ channel blockers or amiodarone. Quinidine must not be used in this arrhythmia, since it accelerates AV-conduction due to its vagolytic effect. 

Atrial flutter Rapid contraction of the atria (up to 300 bpm) at a rate too rapid for the ventricles to pump efficiently... 

The uses of the antiarrhythmic drug are given in the Summaiy Drug Table Antiarrhythmic Drug3. In general these drugp are used to prevent and treat cardiac arrhythmias, such as premature ventricular contractions (PVCs), ventricular tachycardia (VT), premature atrial contractions (PACs), paroxysmal atrial tachycardia (PAT), atrial fibrillation, and atrial flutter. Some of the antiarrhythmic dru are used for other... 

Many patients have a rhythm that varies between atrial flutter and AF. Atrial flutter is associated with a 40% higher risk of stroke. Given that the concordance of the AF and atrial flutter is high, anticoagulation should be considered in patients with atrial flutter and coexisting cardiac pathology predisposing to left atrial thrombus. 

Management of Stable Atrial Fibrillation/Atrial Flutter... 

Duration of atrial fibrillation/atrial flutter >48 h or unknown, o Electrical or chemical cardioversion in a patient without adequate anticoagulation may cause embolization of atrial thrombi. 

Resynchronize after each cardioversion ° Paroxysmal SVT and atrial flutter often respond to lower energy doses (may start with 50J)... 

Dose to achieve an INR between 2 and 3 if concomitant atrial fibrillation or atrial flutter... 

Atrial flutter cardioversion o Same as atrial fibrillation... 

Heart Fever, lethargy, weakness, SOB, DOE, hypotension, tachycardia, atrial flutter, ventricular arrhythmias Leukocytosis, endomyocardial biopsy positive for mononuclear infiltrates... 

EKGs taken on two workers about 2.5 hours after an acute exposure to hydrogen sulfide showed cardiac arrhythmias (Krekel 1964). The workers were exposed for <5 minutes after a spill of sodium sulfide that broke down to release hydrogen sulfide. In one individual, a negative P wave indicating a substitute rhythm was noted, while in the other individual a continuous arrhythmia due to atrial flutter was found. EKGs for both men had returned to normal within 24 hours. 

Common supraventricular tachycardias requiring drug treatment are atrial fibrillation (AF) or atrial flutter, paroxysmal supraventricular tachycardia (PSVT), and automatic atrial tachycardias. Other common supraventricular arrhythmias that usually do not require drug therapy are not discussed in this chapter (e.g., premature atrial complexes, wandering atrial pacemaker, sinus arrhythmia, sinus tachycardia). 

Atrial flutter is characterized by rapid (270 to 330 atrial beats/min) but regular atrial activation. The ventricular response usually has a regular pattern and a pulse of 300 beats/min. This arrhythmia occurs less frequently than AF but has similar precipitating factors, consequences, and drug therapy. 

The predominant mechanism of AF and atrial flutter is reentry, which is usually associated with organic heart disease that causes atrial distention (e.g., ischemia or infarction, hypertensive heart disease, valvular disorders). Additional associated disorders include acute pulmonary embolus and chronic lung disease, resulting in pulmonary hypertension and cor pulmonale and states of high adrenergic tone such as thyrotoxicosis, alcohol withdrawal, sepsis, or excessive physical exertion. 

AF or atrial flutter may be manifested by the entire range of symptoms associated with other supraventricular tachycardias, but syncope is not a common presenting symptom. An additional complication of AF is arterial embolization resulting from atrial stasis and poorly adherent mural thrombi, which accounts for the most devastating complication embolic stroke. Patients with AF and concurrent mitral stenosis or severe systolic HF are at particularly high risk for cerebral embolism. 

The desired outcome depends on the underlying arrhythmia. For example, the ultimate treatment goals of treating AF or atrial flutter are restoring sinus rhythm, preventing thromboembolic complications, and preventing further recurrences. 

Cardiovascular manifestations include hypertension and cardiac arrhythmias (e.g., heart block, atrial flutter, paroxysmal atrial tachycardia, ventricular fibrillation, and digitalis-induced arrhythmias). In severe hypokalemia (serum concentration <2.5 mEq/L), ECG effects include ST-segment depression or flattening, T-wave inversion, and U-wave elevation. 

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