Atrial Flutter

Atrial flutter is often referred to as ‘Flutter’. It refers to an abnormal rhythm that occurs in the right atrial chamber. It is often referred to as typical flutter. Unlike atrial fibrillation, flutter is an organised and fixed rapid electrical circuit that results in fast conduction of signals to the ventricles resulting in fast or rapid heart rate that can be regular or irregular.

Many of the treatment recommendations and precautions for atrial fibrillation applies to atrial flutter. It may occur together with AF in some people. More than 50% of people with an initial diagnosis of atrial flutter go onto have AF at some stage.

Flutter does increase the risk of stroke, heart failure and other complications.

Medications are not always effective in controlling atrial flutter but is still generally recommended as treatment. Atrial flutter can be effectively managed with catheter ablation.

Are there different types of Atrial flutter? 

Yes, there can be many types of atrial flutter. A typical / usual atrial flutter is a specific type of abnormal heart rhythm characterised by a regular, rapid heartbeat originating from the right atria of the heart. In typical atrial flutter, the electrical signals in the atria travel in a predictable pattern around the tricuspid valve, forming a circuit. This circuit causes the atria to contract rapidly, typically at a rate of around 250 to 350 beats per minute. However, due to the atrioventricular (AV) node’s protective function, the ventricles (lower chambers of the heart) receive fewer of these rapid signals, resulting in a lower heart rate compared to the atrial rate.

The characteristic electrocardiogram (ECG) pattern of typical atrial flutter appears as a sawtooth-shaped flutter waves on the ECG tracing. The regularity and distinctive appearance of these flutter waves help differentiate atrial flutter from other arrhythmias.

Other types of atrial flutter are often collectively called atypical flutter. Treatment and long-term management are highly variable depending on specific circumstances.

What is the long-term prognosis with atrial flutter?

The prognosis will depend on the coexistence of AF. Prognosis can vary depending on several factors, including the individual’s overall health, the presence of underlying heart conditions, and the effectiveness of treatment and management strategies.

It’s important to note that while atrial flutter and AF can have significant implications, appropriate management and treatment can help improve outcomes and minimize the associated risks. Regular medical follow-ups, adherence to prescribed medications, lifestyle changes (such as maintaining a healthy weight, exercising regularly, and managing other health conditions), and compliance with treatment recommendations are crucial for optimizing the long-term prognosis for individuals with AF.

In many cases, once the correct management strategies and treatment have been instituted, you are expected to lead a normal life.

What are the treatment options for atrial flutter?

Medications:

Medications are generally the first line treatment in the management of AF and atrial flutter. Medications can be used for two reasons. First is to prevent a stroke. Second is to control your heart rhythm.

Medications used to prevent strokes are collectively referred to as anticoagulants. The necessity and duration of anticoagulant therapy vary and depend on factors such as age and other individual risk factors. The risk of stroke is often assessed using a commonly used scoring system called the CHA₂DS₂-VASc score.

Medications are also employed to control abnormal heart rhythms, either by stopping rapid heartbeats or regulating the heart rate. However, for individuals who experience ongoing episodes of AF despite medication use, have intolerances to prescribed medications, or prefer not to rely on long-term medication, procedural options may be considered. In certain cases, the use of medications may necessitate the placement of a pacemaker for safe administration.

There are multiple medications and combinations available that can be prescribed to address AF. Finding the most effective medication often involves a process of trial and adjustment of dosage and medication type to determine their efficacy. Regular monitoring is typically required for medications that target abnormal heart rhythms.

Heart rhythm medications can be used either on a regular basis or as needed in a “pill-in-pocket” strategy for acute AF episodes.

It is important to consult with your healthcare provider to determine the appropriate medication regimen for your specific situation. They will also provide guidance on dosage, medication adjustments, and the need for regular monitoring to ensure optimal management of AF.

Procedural options:

An electrical cardioversion: In this procedure, an electrical shock is delivered to the heart through electrodes placed on the chest. The shock is synchronised with the heart’s electrical activity to ensure it is delivered during a specific phase of the cardiac cycle. The electrical energy briefly interrupts the abnormal heart rhythm and allows the heart’s natural pacemaker to re-establish a normal sinus rhythm. Electrical cardioversion is usually performed under sedation or general anaesthesia to minimize discomfort.

A Catheter ablation: is a common and minimally invasive procedure where the flutter circuit is identified and ablated to prevent recurrence.

Pacemaker and AV node ablation: The choice of a pacemaker implantation and atrioventricular (AV) node ablation is considered as a final treatment option when medications and other ablation procedures prove ineffective in controlling rapid heart rhythms associated with atrial fibrillation (AF) or flutter. This treatment approach involves two steps.

First, a pacemaker is implanted to assist in regulating the heart’s rhythm. The pacemaker monitors the heart’s electrical activity and delivers electrical impulses as needed to maintain a

stable and regular heartbeat.

Following the pacemaker implantation, an AV node ablation procedure is performed several weeks later. During this procedure, the AV node, which is responsible for conducting electrical signals between the atria and ventricles, is intentionally ablated. This prevents the heart from beating in a disorganised manner caused by AF or flutter. The pacemaker then takes over the role of regulating the heart’s rhythm.

While AF or flutter continues to exist in the background, it no longer causes the heart to race. Long-term anticoagulant medication therapy is still necessary to prevent the risk of stroke associated with AF and flutter.

The decision to pursue pacemaker implantation and AV node ablation as a treatment option is made by a healthcare professional based on an individual’s specific circumstances and the severity of their arrhythmia-related rapid heart rhythms. Close monitoring and regular follow-up with the healthcare team are important after the procedure to ensure proper functioning of the pacemaker and ongoing management of your arrhythmia.