Atrial flutter

Patients presenting with acute atrial flutter who have paroxysmal, persistent, or permanent atrial flutter need long-term follow-up.

• Depending on the nature of the underlying cause (i.e., coronary artery disease, valvular heart disease, or heart failure), patients should have regular follow-up at a minimum of every 3 to 6 months.

• Patients who are taking antiarrhythmic agents need follow-up ECG monitoring. Exercise stress testing is recommended to assess for drug-related ventricular tachycardia due to proarrhythmic effects of flecainide and propafenone.

• A regular follow-up to check and monitor the international normalized ratio is mandatory for patients who are taking warfarin for anticoagulation.

For patients with persistent atrial flutter that is felt to be secondary to a reversible cause, long-term follow-up may not be necessary after the initial treatment and evaluation of the atrial flutter, if the cause has been removed. For patients requiring continued therapy due to high risk of recurrence, follow-up should generally include the following general categories:

• Adequate treatment of the associated medical/cardiac diagnosis

• Periodic assessments of efficacy of therapy

• Periodic evaluation for the adverse effects or complications of the therapy

• Maintenance and monitoring of adequate anticoagulation

• Reevaluation of the current therapy if the underlying cardiovascular problem changes or progresses or the atrial flutter becomes permanent.

In the few patients with atrial flutter who have asymptomatic recurrences irrespective of the therapy (antiarrhythmic drug or ablation), chronic anticoagulation should be considered long term. If the patient is symptomatic, evaluation with Holter monitor, event monitor, or pacemaker/implantable cardioverter-defibrillator interrogations can be considered, largely to assure that ventricular rates are controlled, and to measure the number and duration of atrial flutter episodes. Clearly any change in the clinical status of a patient with a history of atrial flutter should prompt the physician to look for a recurrence as the cause of the clinical change.