Highlights & Basics
- Atrial flutter, in the typical form, 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.
Quick Reference
History & Exam
Key Factors
Other Factors
Diagnostics Tests
Treatment Options
Definition
Epidemiology
Etiology
Pathophysiology
Images
Typical atrial flutter with variable (3 to 4:1) block
Atrial fibrillation
Atrial flutter typically involves a circuit in the right atrium
Left panel: atrial activation in typical atrial flutter (AFL). Right panel: activation in reverse typical AFL. The atria are represented schematically in a left anterior oblique view, from the tricuspid (left) and mitral rings. The endocardium is shaded and the openings of the superior (SVC) and inferior vena cava (IVC), coronary sinus (CS), and pulmonary veins (PV) are shown. The direction of activation is shown by arrows. Dashed areas mark approximate location of zones of slow conduction and block. Lettering on the right-hand panel marks the low (LPS), mid (MPS), and high (HPS) posteroseptal wall, respectively
Close-up images of leads V1, II, III, aVF demonstrating the features of typical atrial flutter: positive saw-tooth deflections in lead V1 and negative deflections in leads II, III, aVF (arrows)
Reverse typical atrial flutter
Selected leads from a patient with reverse typical atrial flutter confirmed at electrophysiologic study. The atrial deflections are negative in lead V1 and positive in leads II, III, aVF (arrows)
Atypical flutter with right bundle branch block
Close up of leads II, III, V1 showing the continuously undulating pattern of atrial deflections not fitting the criteria for typical or reverse typical atrial flutter
Citations
Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia. J Am Coll Cardiol. 2016 Apr 5;67(13):e27-115.[Abstract][Full Text]
Hindricks G, Potpara T, Dagres N, et al. ESC Scientific Document Group. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498. [Abstract][Full Text]
Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. Circulation. 2024 Jan 2;149(1):e1-156.[Abstract][Full Text]
1. Estes NA 3rd, Halperin JL, Calkins H, et al; American College of Cardiology; American Heart Association Task Force on Performance Measures; Physician Consortium for Performance Improvement. ACC/AHA/Physician Consortium 2008 clinical performance measures for adults with nonvalvular atrial fibrillation or atrial flutter. J Am Coll Cardiol. 2008 Feb 26;51(8):865-84. [Abstract]
2. Saoudi N, Cosío F, Waldo A, et al. A classification of atrial flutter and regular atrial tachycardia according to electrophysiological mechanisms and anatomical bases; a statement from a joint expert group from the Working Group of Arrhythmias of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Eur Heart J. 2001 Jul;22(14):1162-82.[Abstract][Full Text]
3. Lévy S, Camm AJ, Saksena S, et al. International consensus on nomenclature and classification of atrial fibrillation; a collaborative project of the Working Group on Arrhythmias and the Working Group on Cardiac Pacing of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Europace. 2003 Apr;5(2):119-22.[Abstract][Full Text]
4. Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia. J Am Coll Cardiol. 2016 Apr 5;67(13):e27-115.[Abstract][Full Text]
5. Granada J, Uribe W, Chyou P, et al. Incidence and predictors of atrial flutter in the general population. J Am Coll Cardiol. 2000 Dec;36(7):2242-6.[Abstract]
6. Brugada J, Katritsis DG, Arbelo E, et al; ESC Scientific Document Group. 2019 ESC guidelines for the management of patients with supraventricular tachycardia - the Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J. 2020 Feb 1;41(5):655-720.[Abstract][Full Text]
7. Naccarelli GV, Wolbrette DL, Luck JC. Proarrhythmia. Med Clin North Am. 2001 Mar;85(2):503-26;xii.[Abstract]
8. Hindricks G, Potpara T, Dagres N, et al. ESC Scientific Document Group. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498. [Abstract][Full Text]
9. Tisdale JE, Chung MK, Campbell KB, et al. Drug-induced arrhythmias: a scientific statement from the American Heart Association. Circulation. 2020 Oct 13;142(15):e214-33.[Abstract][Full Text]
10. Olgin JE, Zipes DG. Libby: Braunwald's heart disease: a textbook of cardiovascular medicine. 8th ed. Philadelphia, PA: Saunders Elsevier; 2007.
11. Waldo AL. The interrelationship between atrial fibrillation and atrial flutter. Prog Cardiovasc Dis. 2005 Jul-Aug;48(1):41-56.[Abstract]
12. Garson A Jr, Bink-Boelkens M, Hesslein PS, et al. Atrial flutter in the young: a collaborative study of 380 cases. J Am Coll Cardiol. 1985 Oct;6(4):871-8.[Abstract]
13. Frendl G, Sodickson AC, Chung MK, et al. 2014 AATS guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures. J Thorac Cardiovasc Surg. 2014 Sep;148(3):e153-93. [Abstract][Full Text]
14. Kilicaslan F, Verma A, Yamaji H, et al. The need for atrial flutter ablation following pulmonary vein antrum isolation in patients with and without previous cardiac surgery. J Am Coll Cardiol. 2005 Mar 1;45(5):690-6.[Abstract]
15. Kalman JM, Olgin JE, Saxon LA, et al. Electrocardiographic and electrophysiologic characterization of atypical atrial flutter in man: use of activation and entrainment mapping and implications for catheter ablation. J Cardiovasc Electrophysiol. 1997 Feb;8(2):121-44.[Abstract]
16. Akar JG, Kok LC, Haines DE, et al. Coexistence of type I atrial flutter and intra-atrial re-entrant tachycardia in patients with surgically corrected congenital heart disease. J Am Coll Cardiol. 2001 Aug;38(2):377-84.[Abstract]
17. Verma A, Marrouche NF, Seshadri N, et al. Importance of ablating all potential right atrial flutter circuits in postcardiac surgery patients. J Am Coll Cardiol. 2004 Jul 21;44(2):409-14.[Abstract]
18. Seiler J, Schmid DK, Irtel TA, et al. Dual-loop circuits in postoperative atrial macro re-entrant tachycardias. Heart. 2007 Mar;93(3):325-30.[Abstract][Full Text]
19. Kanter RJ, Garson A. Atrial arrhythmias during chronic follow-up of surgery for complex congenital heart disease. Pacing Clin Electrophysiol. 1997 Feb;20(2 Pt 2):502-11.[Abstract]
20. Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. Circulation. 2024 Jan 2;149(1):e1-156.[Abstract][Full Text]
21. National Institute for Health and Care Excellence (UK). Atrial fibrillation: diagnosis and management. 30 Jun 2021 [internet publication].[Full Text]
22. Panchal AR, Bartos JA, Cabañas JG, et al; Adult Basic and Advanced Life Support Writing Group. Part 3: adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020 Oct 20;142(16 suppl 2):S366-468.[Abstract][Full Text]
23. Gallagher MM, Guo XH, Poloniecki JD, et al. Initial energy setting, outcome and efficiency in direct current cardioversion of atrial fibrillation and flutter. J Am Coll Cardiol. 2001 Nov 1;38(5):1498-504.[Abstract][Full Text]
24. Van Gelder IC, Crijns HJ, Van Gilst WH, et al. Prediction of uneventful cardioversion and maintenance of sinus rhythm from direct-current electrical cardioversion of chronic atrial fibrillation and flutter. Am J Cardiol. 1991 Jul 1;68(1):41-6.[Abstract]
25. Arnar DO, Danielsen R. Factors predicting maintenance of sinus rhythm after direct current cardioversion of atrial fibrillation and flutter: a reanalysis with recently acquired data. Cardiology. 1996 May-Jun;87(3):181-8.[Abstract]
26. Vos MA, Golitsyn SR, Stangl K, et al. Superiority of ibutilide (a new class III agent) over DL-sotalol in converting atrial flutter and atrial fibrillation. The Ibutilide/Sotalol Comparator Study Group. Heart. 1998 Jun;79(6):568-75.[Abstract][Full Text]
27. Ellenbogen KA, Stambler BS, Wood MA, et al. Efficacy of intravenous ibutilide for rapid termination of atrial fibrillation and atrial flutter: a dose-response study. J Am Coll Cardiol. 1996 Jul;28(1):130-6.[Abstract][Full Text]
28. Abi-Mansour P, Carberry PA, McCowan RJ, et al. Conversion efficacy and safety of repeated doses of ibutilide in patients with atrial flutter and atrial fibrillation. Study Investigators. Am Heart J. 1998 Oct;136(4 Pt 1):632-42.[Abstract]
29. Stambler BS, Wood MA, Ellenbogen KA, et al. Efficacy and safety of repeated intravenous doses of ibutilide for rapid conversion of atrial flutter or fibrillation. Ibutilide Repeat Dose Study Investigators. Circulation. 1996 Oct 1;94(7):1613-21.[Abstract][Full Text]
30. Spector P, Reynolds MR, Calkins H, et al. Meta-analysis of ablation of atrial flutter and supraventricular tachycardia. Am J Cardiol. 2009 Sep 1;104(5):671-7. [Abstract]
31. Pérez FJ, Schubert CM, Parvez B, et al. Long-term outcomes after catheter ablation of cavo-tricuspid isthmus dependent atrial flutter: a meta-analysis. Circ Arrhythm Electrophysiol. 2009 Aug;2(4):393-401.[Abstract][Full Text]
32. Rodgers M, McKenna C, Palmer S, et al. Curative catheter ablation in atrial fibrillation and typical atrial flutter: systematic review and economic evaluation. Health Technol Assess. 2008 Nov;12(34):iii-iv;xi-xiii;1-198.[Abstract][Full Text]
33. Vassallo P, Trohman RG. Prescribing amiodarone: an evidence-based review of clinical indications. JAMA. 2007 Sep 19;298(11):1312-22.[Abstract][Full Text]
34. Andrade JG, Aguilar M, Atzema C, et al; Members of the Secondary Panel. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society comprehensive guidelines for the management of atrial fibrillation. Can J Cardiol. Can J Cardiol. 2020 Dec;36(12):1847-948.[Abstract][Full Text]
35. You JJ, Singer DE, Howard PA, et al. Antithrombotic therapy for atrial fibrillation: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 suppl):e531S-75S. [Abstract][Full Text]
36. Seidl K, Hauer B, Schwick NG, et al. Risk of thromboembolic events in patients with atrial flutter. Am J Cardiol. 1998 Sep 1;82(5):580-3.[Abstract]
37. Weiss R, Marcovitz P, Knight BP, et al. Acute changes in spontaneous echo contrast and atrial function after cardioversion of persistent atrial flutter. Am J Cardiol. 1998 Nov 1;82(9):1052-5.[Abstract]
38. Sparks PB, Jayaprakash S, Vohra JK, et al. Left atrial "stunning" following radiofrequency catheter ablation of chronic atrial flutter. J Am Coll Cardiol. 1998 Aug;32(2):468-75.[Abstract][Full Text]
