In the typical form, this entity is characterized electrocardiographically 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.
If the rhythm persists despite 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, pharmacologic cardioversion may be attempted.
Because of alterations in atrial activation, the ECG often fluctuates between both rhythms in the same patient.
Typical atrial flutter (counterclockwise cavotricuspid isthmus-dependent atrial flutter) is a macroreentrant atrial tachycardia with atrial rates usually above 250 bpm up to 320 bpm. It results from organized electrical activity in which large areas of the atrium take part in the reentrant 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 counterclockwise 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 a counterclockwise 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. This rhythm is closely related to atrial fibrillation.
History and exam
Key diagnostic factors
- worsening heart failure or pulmonary symptoms
- jugular venous pulsations with rapid flutter waves
Other diagnostic factors
- fatigue or lightheadedness
- chest pain
- embolic events
- increasing age
- valvular dysfunction
- atrial septal defects
- atrial dilation
- recent cardiac or thoracic procedures
- surgical or postablation scarring of atria
- heart failure
- antiarrhythmic drugs for atrial fibrillation
- digitalis use
- male gender
- congenital or lone atrial flutter
1st investigations to order
- thyroid function tests
- serum electrolytes
Investigations to consider
- pulmonary function tests
- digitalis level
- cardiac enzymes
- spiral CT with pulmonary embolism protocol
- transthoracic echocardiogram
- atrial electrogram recording
- electrophysiologic studies
recurrent atrial flutter or failure of elective cardioversion
Katherine C. Wu, MD, FACC
Associate Professor of Medicine
Johns Hopkins University
School of Medicine
KCW declares that she has no competing interests.
Richard C. Wu, MD
Associate Professor of Medicine
Cardiac Electrophysiology Laboratory
UT Southwestern Medical Center
RCW declares that he has no competing interests.
Reginald Ho, MD
Clinical Assistant Professor
Department of Medicine
Thomas Jefferson University Hospital
RH declares that he has no competing interests.
George Juang, MD, FACC
Director of Electrophysiology
Long Island Arrhythmia Center
GJ declares that he has no competing interests.
- Atrial fibrillation
- Atrial tachycardia
- 2019 ESC guidelines for the management of patients with supraventricular tachycardia
- 2018 focused update of the Canadian Cardiovascular Society guidelines for the management of atrial fibrillation
Atrial fibrillation: what is it?
Atrial fibrillation: what treatments work?More Patient leaflets
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