Atrial flutter - recognition and emergency department management
Overview
Atrial flutter (AFL) is a macro‑reentrant atrial tachycardia that classically produces a regular, narrow‑complex tachycardia. The ventricular rate is commonly around 140-160 bpm, most often owing to 2:1 AV conduction.
In the emergency department the priorities are rapid ECG recognition, assessment for haemodynamic compromise, appropriate choice of rate versus rhythm control, correct application of anticoagulation rules, and timely referral for definitive therapy when indicated (NICE NG196; Resuscitation Council UK).
Pathophysiology
Typical AFL is usually a cavotricuspid isthmus-dependent reentrant circuit in the right atrium generating atrial rates of approximately 250-350/min. The ventricular rate depends on AV nodal conduction and is commonly 2:1.
Because the atrial activity is organised, AFL is generally more amenable to electrical cardioversion and to catheter ablation than atrial fibrillation. Stroke risk and anticoagulation strategy follow the same principles used for atrial fibrillation (NICE NG196).
Clinical presentation
- Patients commonly present with palpitations, dyspnoea, presyncope, syncope, chest discomfort, fatigue, or decompensated heart failure.
- Onset may be abrupt (paroxysmal) or persistent.
- Any signs of haemodynamic instability (severe hypotension, shock, ongoing ischaemia, acute pulmonary oedema, or altered conscious level) warrant immediate synchronized DC cardioversion.