Atrial flutter is typically characterised on the ECG by flutter waves, which are a saw-tooth pattern of atrial activation, most prominent in leads II, III, aVF, and V1.
Atrial rates are typically above 250 bpm and up to 320 bpm.
Ventricular rates range from 120 to 160 bpm, and most characteristically 150 bpm, because an associated 2:1 atrioventricular block is common.
This rhythm is commonly associated with atrial fibrillation, into which it may degenerate. Atrial fibrillation may also convert to atrial flutter. Because of alterations in atrial activation, the ECG often fluctuates between both rhythms in the same patient.
If a patient is haemodynamically unstable, they should be given emergency electrical cardioversion.
If a patient is haemodynamically stable, the first-line treatment is rate control and management of the underlying cause.
If the rhythm persists in a haemodynamically stable patient, despite rate control and treatment of the underlying cause (or in the absence of a reversible cause), electrical cardioversion is used to terminate the arrhythmia.
If electrical cardioversion is unavailable or not acceptable to the patient, pharmacological cardioversion may be attempted.
Typical atrial flutter (anticlockwise cavotricuspid isthmus-dependent atrial flutter) is a macro re-entrant atrial tachycardia with atrial rates usually above 250 bpm up to 320 bpm. It results from organised electrical activity in which large areas of the atrium take part in the re-entrant circuit. The typical form depends on the so-called cavotricuspid isthmus for part of the circuit: tricuspid annulus as the anterior boundary and the crista terminalis/eustachian ridge as the posterior boundary, as well as the endocardial cavity of the right atrium. The term anticlockwise refers to the direction of activation when the tricuspid annulus is viewed en face, whereby activation occurs up the septum, down the right atrial free wall in an anticlockwise fashion. Characteristic features on ECG are negatively directed saw-tooth atrial deflections (f waves) seen in leads II, III, and aVF, with positively directed deflections in lead V1.
History and exam
Key diagnostic factors
- presence of risk factors
- worsening heart failure or pulmonary symptoms
Other diagnostic factors
- fatigue or lightheadedness
- jugular venous pulsations with rapid flutter or cannon waves
- chest pain
- embolic events
- myocardial ischaemia
- increasing age
- valvular dysfunction
- atrial septal defects
- atrial dilation
- recent cardiac or thoracic procedures
- surgical or post-ablation scarring of atria
- heart failure
- anti-arrhythmic drugs for atrial fibrillation
- digitalis use
- male sex
- congenital or lone atrial flutter
1st investigations to order
- full blood count
- thyroid function tests
- renal function and serum electrolytes
- chest x-ray
- transthoracic echocardiography (TTE)
Investigations to consider
- pulmonary function tests
- digitalis level
- high-sensitivity troponin
- CT pulmonary angiography with clinical probability scoring
- electrophysiological studies
- atrial electrogram
- exercise tolerance testing
- myocardial ischaemia testing
recurrent atrial flutter or failure of elective cardioversion
Resham Baruah, MBBS, BSc MRCP, PhD
Chelsea and Westminster Hospital NHS Foundation Trust
Royal Brompton & Harefield NHS Foundation Trust
RB is specialist advisor to the 2018 NICE guideline on chronic heart failure in adults and is a member of the European Heart Failure Association Task Force on palliative care in heart failure.
RB has received honoraria/speakers’ fees from Novartis and Boehringer Ingelheim.
BMJ Best Practice would like to gratefully acknowledge the previous expert contributor, whose work is retained in parts of the content:
Katherine C. Wu, MD, FACC
Associate Professor of Medicine
Johns Hopkins University School of Medicine
Gregory Lip, MD, FRCP, DFM, FACC, FESC, FEHRA
Price-Evans Professor of Cardiovascular Medicine
University of Liverpool
National Institute for Health Research
Faculty of Medicine
GL is a consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, and Daiichi-Sankyo, for which no fees are received personally.
Section Editor, BMJ Best Practice
AS declares that she has no competing interests.
Lead Section Editor, BMJ Best Practice
RW declares that she has no competing interests.
Comorbidities Editor, BMJ Best Practice
JC declares that she has no competing interests.
Drug Editor, BMJ Best Practice
AM declares that he has no competing interests.
- Atrial fibrillation
- Atrial tachycardia
- Atrial fibrillation: diagnosis and management
- 2019 ESC guidelines for the management of patients with supraventricular tachycardia
Atrial Fibrillation CHA(2)DS(2)-VASc Score for Stroke Risk
HAS-BLED Bleeding Risk ScoreMore Calculators
Heart attack: what is it?
What you can do to prevent another heart attackMore Patient leaflets
- Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer