Atrial flutter

How does the normal heart rhythm function?

The normal heart rhythm originates from a natural pacemaker which is located in the right upper chamber of the heart. The natural pacemaker, known as the sinus node, fires off electrical impulses at regular intervals, akin to a ‘switch’ at the top of the heart going on and off at regular intervals. The electrical activity then spreads to the rest of the heart though specialized channels in the heart, which could be thought of as electrical activity being conducted through a system of ‘wires’. These ‘wires’ conduct electricity from the top chambers to the bottom chambers of the heart. In response to the spread of these electrical impulses, the heart beats at regular intervals.

How does atrial flutter arise?

The heart rhythm abnormality in patients with atrial flutter originates in the upper chambers of the heart. The abnormal electrical activity is the result of an abnormal circuit in the heart (electrical activity continuously and looping around an abnormal electrical circuit). Based on where the abnormal circuit is located in the upper chambers of the heart, atrial flutter maybe described as typical atrial flutter or atypical flutter. Typical atrial flutter is by far the most common type of atrial flutter. As a result of this abnormal circuit, the upper chambers of the heart flutter continuously rather than contracting effectively. Atrial flutter typically results in a rapid heart rhythm which maybe regular or irregular.

What are the symptoms associated with atrial flutter?

The rapid heart rhythm associated with atrial flutter may result in number of symptoms. Patients most commonly experience palpitations (an uncomfortable sensation of a rapid pounding heartbeat or a fluttering sensation). Patients may also experience difficulty breathing, chest pain, dizziness, and in certain circumstances, loss of consciousness. Generally speaking, atrial flutter is not a life-threatening heart rhythm abnormality.

The pattern of atrial flutter is highly variable between patients. The symptoms can vary from short-lived abnormal heart rhythm episodes that stop spontaneously to prolonged episodes lasting for many hours. Amongst patients who have frequent and/or prolonged episodes, the arrhythmia can have a significant impact on quality of life, both from a physical symptom perspective and from a psychological perspective.

How is atrial flutter diagnosed?

Your physician will take a detailed history with particular emphasis on the pattern of the symptoms, the frequency of symptoms and any triggers of your arrhythmia. In the majority of cases, a diagnosis of atrial flutter is made using an electrocardiographic (ECG) heart tracing. If a patient has an ECG during an episode of atrial flutter, the diagnosis is relatively simple as atrial flutter is associated with typical changes on an ECG.

In a proportion of cases, capturing the atrial flutter on an ECG may represent a challenge as it is not practical to perform the ECG during an episode of arrhythmia (for example, because the heart rhythm abnormality stops before a patient reaches the hospital or GP surgery). In these circumstances, your physician may arrange more advanced tests to monitor the heart rhythm over a prolonged period of time (typically one day to one week depending on the frequency of symptoms). Examples of such tests include Holter monitors and event recorders.

What are the treatment options for atrial flutter?

There are a number of parallels in the treatment strategies for atrial flutter and atrial fibrillation. Treatment of atrial flutter focuses on two main areas. The first is prevention of stroke, with anticoagulant (blood thinning) medications and the second is eliminating symptoms with the aim of improving quality of life.

Preventing stroke in atrial flutter patients

The decision to start blood thinners is based on the specific risk profile for stroke in a patient with atrial flutter. Amongst patients who do not have any risk factors, blood thinning medications may not be necessary. In the presence of one or more of the risk factors below, your physician may recommend treatment with blood thinning medications:

  • Age above 65 years
  • History of heart failure
  • High blood pressure
  • Diabetes
  • Previous stroke or transient ischaemic attack (TIA)
  • Disease in the heart arteries or other major arteries
  • Female sex*

*Only counts if one of the other risk factors are present

Treatment of symptoms of atrial flutter

The treatment of atrial flutter can be divided into what can be done to stop an episode of atrial flutter once it starts and what can be done to prevent future episodes from occurring. An episode of atrial flutter can be stopped by treatment with specific drugs, performing an electrical cardioversion, or proceeding directly to performing a catheter ablation procedure.

Amongst patients in whom a previous episode of atrial flutter has been stopped with drugs or an  electrical cardioversion, prevention of future episodes may involve taking daily medications to suppress the arrhythmia or performing a catheter ablation procedure. A patient’s decision to pursue a catheter ablation procedure may be influenced by adverse side effects associated with medications, the inconvenience of having to take regular medications and/or failure of medications to suppress the arrhythmia. Catheter ablation for atrial flutter is often preferred to long-term treatment with medications for typical (common) atrial flutter due to the high success rates of the procedure.

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