Atrial Flutter

A rapid atrial rhythm (approximately 300/minute in the atria) caused by a re-entry loop within the atria; since the junction is unable to conduct 300 impulses/ minute (max=240), the junction often allows every 2nd, 3rd, or 4th impulse through; resulting ventricular rate is approximately 150, 100, and 75/min. respectively.

Atrial flutter occurs from a rapid conducting loop (reentrant) within the atria that fires at rates between 260-340 minute. Typically, though, the atria flutter at rates close to 300/minute. This rate is faster than the AV junction’s capacity (maximum is 240 impulses/minute). As a result, the AV junction conducts only the 2nd, 3rd or 4th impulse to the ventricle, usually in a consistent pattern.

With only every 3rd or 4th impulse conducted, an abundance of P waves are seen between the QRS complexes. These flutter (‘P’) waves resemble the teeth of a saw. Flutter waves are easily seen at these slower ventricular rates.

Since the atria flutter at rates of about 300/minute, a 2:1 conduction is the most common presentation of atrial flutter with ventricular rates of close to 150/minute. With 2:1 conduction, flutter waves do not usually appear (P waves are generally buried in either the QRS or the T wave). For any supraventricular rhythm with a rate close to 150/minute, consider atrial flutter.

If the patient is in atrial flutter, a vagal maneuver can slow the AV node, effectively increasing the number of visible flutter waves.

If a patient is in supraventricular tachycardia with a heart rate close to 150/minute, always consider the possibility that the rhythm is atrial flutter with a 2:1 block. Failure to detect this rhythm can lead to serious complications for those with Woolf-Parkinson-White syndrome or occasionally for those who have been in atrial flutter for more than 48 hours (risk of emboli).

Atrial flutter is often grouped with atrial fibrillation. Risk factors of atrial fibrillation can also apply to atrial flutter, though with less frequency. Atrial flutter also has a tendency to deteriorate into atrial fibrillation.

The 3 step process would probably take us to atrial flutter. The P waves are more indicative of an atrial locus. The appearance of more than one P wave between each QRS complex is a somewhat unique condition.

The simplest way to detect the number of flutter waves for every QRS complex is to complete some simple math. Determine the ventricular rate. If the atria are fluttering at rates close to 300/minute, divide the ventricular rate into 300 and round off your answer. For example, if the ventricle rate is 100/minute with flutter waves, the atria flutters 3 times for every (300/100) ventricular depolarization. You would call this rhythm atrial flutter with a 3:1 response.

atrial flutter, HR 78/min

1. Six Second ECG Guidebook (2012), T Barill, p. 123-124, 191

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