History and exam
Key diagnostic factors
common
worsening heart failure or pulmonary symptoms
These are common underlying conditions, and worsening of symptoms may indicate other decompensation or new-onset atrial flutter.
jugular venous pulsations with rapid flutter waves
Rapid flutter waves can be noted in the jugular venous wave form.
Other diagnostic factors
common
palpitations
Classic symptom, but because atrioventricular block usually results in normal ventricular rate, patients may not have this symptom.
fatigue or lightheadedness
Nonspecific but can be the main presenting symptom.
uncommon
chest pain
Can be symptom of atrial flutter, underlying myocardial ischemia, or a pulmonary embolic event.
dyspnea
Can be a symptom of atrial flutter, underlying myocardial ischemia or a pulmonary embolic event.
syncope
Rare presentation of atrial flutter.
hypotension
Rare presentation of atrial flutter. Atrioventricular block typically results in normal ventricular rate and preservation of blood pressure.
embolic events
Such as stroke. Rare presentation of atrial flutter.
Risk factors
strong
increasing age
valvular dysfunction
Mitral or tricuspid valve stenosis or regurgitation can lead to atrial dilation. Dilation promotes the development and maintenance of reentrant circuits.
atrial septal defects
Can lead to atrial dilation. Dilation promotes the development and maintenance of reentrant circuits.
atrial dilation
Some pathologic conditions can lead to atrial dilation; or, rarely, this occurs in the absence of structural heart disease. Dilation promotes the development and maintenance of reentrant circuits.
recent cardiac or thoracic procedures
Although atrial fibrillation is the most common postcardiac surgery arrhythmia, atrial flutter can occur and is due to pericarditis, alterations in autonomic tone, or atrial ischemia.[4][13]
Transient atrial flutter in the first 2 months after pulmonary vein isolation procedures is common and may not necessitate long-term treatment. Can occur in up to 55% of such patients.[14]
surgical or postablation scarring of atria
Any surgical incision involving the atria can result in atrial flutter with the flutter circuit involving atypical isthmuses between anatomic barriers, prior atrial incision sites, and scarred regions, as well as the cavotricuspid isthmus.[4][12][14][15][16][17][18]
Scarring from prior atrial ablation lesions can lead to development of a reentrant circuit.[14]
Approximately 10% to 30% incidence at 5- to 10-year follow-up after congenital heart disease operative corrections.[19] May also be associated with procedures such as valve surgery, in which atrial incisions or maze procedures were performed.
heart failure
The risk of developing atrial flutter is increased 3.5 times in the presence of heart failure. In 16% of patients with atrial flutter, the arrhythmia was attributable to heart failure in a population-based epidemiologic study.[5]
hyperthyroidism
May precipitate atrial fibrillation or atrial flutter.
COPD
In 12% of patients with atrial flutter, the arrhythmia was attributable to COPD in a population-based epidemiologic study.[5] May precipitate atrial fibrillation or atrial flutter.
asthma
May precipitate atrial fibrillation or atrial flutter.
pneumonia
May precipitate atrial fibrillation or atrial flutter.
weak
antiarrhythmic drugs for atrial fibrillation
Conversion of paroxysmal atrial fibrillation to chronic, incessant atrial flutter has been noted most commonly with Vaughan Williams class Ic drugs (flecainide and propafenone) and with class Ia (disopyramide, procainamide, quinidine) and amiodarone.[7][8] Can occur in up to 15% to 20% of patients treated with propafenone, flecainide, and amiodarone.[4]
diabetes
Atrial flutter is more common in those with a history of diabetes.[5]
digitalis use
Rarely, atrial flutter occurs as a result of digitalis (e.g., digoxin) toxicity.
male sex
Incidence is 2.5 times higher in men than in women.[5]
congenital or lone atrial flutter
This is rare.[10]
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