Atrial Flutter
What is Atrial Flutter?
Atrial flutter is a common rhythm disturbance encountered in Heart Rhythm Clinics throughout the UK. Although not as common as atrial fibrillation it is closely related and it is often the case that patients with atrial flutter can have concomitant atrial fibrillation or indeed go on to develop atrial fibrillation after their atrial flutter is treated. It is generally more common in older patients and is important to identify as it is far more straightforward to cure than atrial fibrillation.
In the majority of patients with atrial flutter their heart rhythm disturbance comes from the right atrium (as opposed to the left atrium which is the site of origin for most patients with atrial fibrillation). Typically the atria beat at between 270 and 300 beats per minute and send all their impulses down to the AV node and often half or a third will get through to the ventricle. As such it’s quite common for patients to have a very elevated but regular heart rate at perhaps 150 or 100 if the atrial flutter is conducting at either 2:1 or 3:1.
What are the typical symptoms?
The most common presenting complaint will be breathlessness and palpitations. Other symptoms include chest pain, light headedness or lethargy.
Some patients who have had atrial flutter for a long time can develop heart failure as the heart does not like to beat quickly for long periods of time.
It is best to be seen by a specialised electrophysiologist/cardiologist who will be able to manage your flutter appropriately.
The goals of treatment are to establish anti coagulation if indicated and to try and get the patient out of atrial flutter by either a cardioversion or catheter ablation.
Atrial Flutter FAQ's
As previously discussed atrial flutter has many similarities to atrial fibrillation and has such often has the same kinds of triggers that atrial fibrillation does. Generally speaking men are twice as likely to get atrial flutter as women and conditions that can lead to the development of atrial flutter include high blood pressure, coronary artery disease, overactive thyroid gland, heart valve disease (valves are either leaking or narrow), cardiomyopathy (weakness to the heart muscle), excessive alcohol, chest infections and pulmonary emboli (clots on the lung). Rarer causes of atrial flutter include congenital heart disease (abnormal structures present at birth, inflammation of the heart sac (pericarditis) and postoperative cardiac surgery.
The cornerstone of diagnosing atrial flutter is an ECG. It will look different to an ECG of atrial fibrillation in that the atrial rhythm is more organised and often has a “saw tooth” appearance. If your flutter is present all the time (persistent) then an ECG will give us the answer immediately. If your flutter is intermittent (paroxysmal) we will need some heart monitoring at a time when you are having your typical symptoms so we can capture it on paper. Heart monitors can be attached to patients for anything between 24 hours or hand held monitors that will extend out to 3 weeks.
Newer smart phone apps such as AliveCor monitors (Kardia) can also help to track down a diagnosis. It is also important to make sure that patients do not have an overactive thyroid gland (with thyroid blood tests), that their blood pressure is normal (simple blood pressure measurement) and it’s also sensible to get an echocardiogram so we can establish that your heart function is normal and that you don’t have a cardiomyopathy or any heart valve disease/signs of a previous heart attack.
There are two cornerstones of therapy. The first is to establish if patients need blood thinning treatment in the form of warfarin or the newer anticoagulant drugs such as Rivaroxaban, Apixaban, Dabigatran or Edoxaban. The second is to manage the rhythm itself. If the flutter is persistent (ie; patients are in it all the time) the goal is to get the patient out of the flutter. This can be performed by a simple cardioversion (see patient information) or more effectively and more permanently with catheter ablation.
Catheter ablation is a procedure done under local anaesthetic with mild sedation and normally takes between 60 and 90 minutes to perform). Two tubes are introduced from the right groin up into the heart. The flutter typically goes through a structure called the cavo tricuspid isthmus in the right atrium. By burning across this structure we break the circuit and restore the heart back to normal rhythm.
The ablation can also be performed if your flutter is intermittent or paroxysmal. This will stop attacks of flutter coming on down the line. It is generally a safe procedure with a small risk of damaging the blood vessel and the groin (less than 1%) and a small risk of bleeding around the heart (tamponade – again less than 1%).
Patients do not want to go down the route of flutter ablation then drug treatments can be used in the form of beta-blockers, Amiodarone, Dronedarone, calcium channel blockers but these are generally much less effective than ablation and do mean that patients have to stay on drugs long term.
If you have a very low risk profile and flutter is successful ablated then often in the weeks after a flutter ablation the anticoagulants can be withdrawn. However if your risk profile is moderately elevated I generally recommend that patients stay on anticoagulants long term because of it’s association with atrial fibrillation. That is to say we can successfully cure you of atrial flutter but months or years down the line you can go on to develop atrial fibrillation and if the anticoagulants have been stopped this can expose you to the risk of stroke. These questions can be discussed in detail at consultation with your cardiologist/electrophysiologist.
What are the Procedures?
These are the procedures associated with Atrial Flutter