Atrial flutter on ECG what are these symptoms and medication

Myocardial fibrillation, atrial flutter have similar mechanisms of appearance, but also a number of differences. The first term refers to the supraventricular type of tachyarrhythmias. At this point, heartbeats become chaotic, and the frequency when counting reaches 350-750 beats per minute. The presented feature excludes the possibility of rhythmic atrial work with atrial fibrillation.

Depending on the classification, fibrillation is divided into several forms. Development mechanisms may have some differences from each other. These include the following:

  • provoked by a specific disease;
  • atrial fibrillation at rest, permanent form;
  • hyperadrenergic;
  • potassium deficiency;
  • hemodynamic.

A constant form of atrial fibrillation (or paroxysmal) becomes a manifestation of a number of diseases. In many patients, mitral stenosis, thyrotoxicosis, or atherosclerosis are most often found. The circle of patients with arrhythmia with a dystrophic process in the alcoholic myocardium, diabetes mellitus and hormonal imbalance is expanding.

Paroxysmal arrhythmia occurs in patients in a horizontal position. During sleep, they often awaken from unpleasant symptoms. It can appear with a sharp turn of the body when a person is lying. The mechanism of occurrence of such disorders is associated with pronounced reflex effects on the vagus nerve myocardium.

Under their influence, the conduction of nerve impulses in the atria slows down. For this reason, fibrillation begins with them. The described form of cardiac arrhythmias is able to normalize itself. This is due to a decrease over time of exposure from the nerve to the muscle.

Hyperadrenergic paroxysms are more common than those described above. They appear in the morning and during physical and emotional stress. The last, chronic variant of arrhythmia is called hemodynamic.

It is attributed to stagnant forms of pathology, which is associated with the presence of an obstacle to the normal contraction of the myocardium. Gradually, the atria begin to expand. The leading place among the reasons is occupied by the following:

  • weakness of the wall of the left ventricle;
  • narrowing of the lumen of the holes between the cavities in the heart;
  • insufficiency of the valve apparatus function;
  • reverse blood flow (regurgitation) in the atrium;
  • tumor-like formations in the cavities;
  • thrombosis;
  • chest trauma.

In many cases, fibrillation becomes a manifestation of the disease. For this reason, before starting treatment, you need to establish its origin.

Flutter is characterized by heartbeats up to 350 per minute. This form is called supraventricular or atrial myocardial flutter. Tachyarrhythmia differs from that described above by the presence of the correct rhythm in most patients.

There are people with features of such a disease. Their normal sinus contractions alternate with episodes of flutter. The rhythm is called permanent. This variant of the pathology of the heart has the following etiology (causes):

  • CHD (coronary heart disease);
  • malformations of rheumatic origin;
  • pericarditis;
  • myocarditis;
  • arterial hypertension;
  • after surgery for defects or shunting;
  • emphysema.

Tachysystolic rhythm occurs in patients with diabetes mellitus, insufficient potassium levels in the blood, with intoxication with drugs and alcohol. The basis of pathogenesis (development mechanism) is repeated repeated excitation in the myocardium. Paroxysm is explained by the circulation of such impulses a large number of times.

The provoking factors include episodes of flickering and ectrasystole. The frequency of contractions in the atria increases to 350 beats per minute.

Unlike them, the ventricles cannot. This is due to the lack of opportunity for the pacemaker to high bandwidth. For this reason, they are reduced by no more than 150 per minute. The permanent form of atrial fibrillation is characterized by blocks, which explains such differences between the cardiac cavities.


– rheumatism (especially in the presence of mitral stenosis (

– coronary artery disease,

– acute myocardial infarction,

– acute or chronic pulmonary heart,

– non-specific chronic lung diseases,

– obstructive chronic lung disease,

– in adults, an atrial septal defect,

– WPW – syndrome (ventricular pre-excitation syndrome)

– SSSU (sinus node dysfunction) or else this is called tahi-brady syndrome,

– pathological (atypical) atypical desympathization,

The pathogenetic significance of atrial flutter.

The main pathological factor is the excessively high frequency of atrial contractions and all the symptoms resulting from this.

Against the background of developing tachysystole, contractile diastolic myocardial dysfunction appears in the region of the left ventricle, which subsequently passes into contractile systolic dysfunction. Ultimately, this picture can go into dilated cardiomyopathy and result in heart failure.

Paroxysmal form of atrial flutter.

With this form of the course of the disease, the frequency of paroxysms, that is, seizures, can be from one per year to several per day.

A feature of paroxysmal atrial flutter is that there is no age or gender category. Attacks can occur in both men and women of any age. But of course, most often in people with myocardial disease.

Paroxysms can occur against the background of physical or emotional stress, overeating, drinking alcohol, with a sharp decrease in external temperature (immersion in cold water, going outside in winter, and so on) and even when drinking a lot of water or upset stomach.

The patient often describes the attack of atrial flutter as a sensation of a strong and frequent heartbeat that appears after some event or action. In more severe cases, dizziness, weakness, loss of consciousness, and even short-term cardiac arrest during the episode of atrial flutter during high-frequency conduction in the AV node (1: 1) are observed.

The constant form of atrial flutter.

This is a very dangerous form, since in the first stages of the development of the disease it usually proceeds asymptomatically and manifests itself with the accumulation of the consequences of a decrease in systemic blood pressure and arterial system pressure, which ultimately leads to a decrease in coronary blood flow. Patients usually come to the doctor with already expressed symptoms of heart failure.

Arrhythmia occurs against a background of heart disease or as a postoperative complication (usually in the first week after surgery on the heart).

Fluttering heart diseaseFactors that increase the risk of developing this arrhythmia
Mitral valve stenosisChronic lung disease
Inflammation (myocarditis, pericarditis)Hypokalemia (insufficient amount of potassium in the body)
WPW syndromeAtrial extrasystole of uncertain etiology
Age older than 60 years
Bad habits
Male gender (in men, pathology occurs 4,5 times more often than in women)

Sometimes paroxysms appear under the influence of these negative factors, and sometimes spontaneously.

Atrial fibrillation and flutter develops for the same reason – structural damage to the myocardium of the atria. In the vast majority of cases, this pathology develops against the background of an existing cardiological pathology.

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Isolated atrial flutter in the absence of other structural and functional lesions of the heart muscle is extremely rare. As a rule, these cases are caused by alcohol abuse (arrhythmia as a component of alcoholic cardiomyopathy) and hyperthyroidism (“thyrotoxic heart”).


In accordance with the pathophysiological classification of H. Wells (1979), typical and atypical atrial flutter are distinguished.

  • Typical atrial flutter (type I). The pathological excitation wave is directed counterclockwise along the atrial septum upward, passes to the posterior wall of the right atrium, after which, bypassing the mouth of the superior vena cava, it descends along the anterior and lateral walls near the inferior vena cava. Having reached the tricuspid ring (the fibrous base of the tricuspid valve), this wave returns to its starting point through isthmus, and the cycle repeats.
  • Atypical atrial flutter (type II). This type includes all other types of flutter, in which the path of the pathological impulse does not include isthmus.

The H. Wells classification is widely used in cardiac surgery, in particular for planning radiofrequency ablation (RFA).

From a clinical point of view, it is advisable to distinguish two forms of atrial flutter:

  • Paroxysmal form of atrial flutter. Arrhythmia occurs spontaneously or under the influence of provoking factors, does not last long.
  • The constant form of atrial flutter. Heart rhythm disturbance exists constantly.

The selection of these fundamentally different forms from each other is due to differences in treatment approaches. Measures that are highly effective in the case of paroxysm of atrial flutter are ineffective with a constant form of arrhythmia, and vice versa.


The attack develops suddenly. During it, the patient feels a strong heartbeat or discomfort in the heart. Often patients describe their feelings as “interruptions” in the work of the heart, the heart “rumbles”, “jumps out of the chest”.

Paroxysm is also accompanied by weakness, dizziness, low blood pressure, sometimes shortness of breath.

Sometimes atrial flutter is asymptomatic (especially if the frequency of contractions of the ventricles is normal). But treatment is still necessary, since this arrhythmia can lead to dangerous complications.

Symptoms of atrial flutter are similar to those with atrial fibrillation. The patient complains of a sensation of a heartbeat, a “revolution” of the heart, which is directly caused by a violation of the heart rhythm.

Hemodynamic disorders that occur with atrial flutter can be accompanied by the following symptoms:

  • Dizziness.
  • Fainting.
  • Shortness of breath during physical exertion and at rest.
  • Angina pectoris and cardialgia.

Paroxysm of atrial flutter usually has a pronounced clinical picture. Against the background of relatively good health, the symptoms described above arise, which is often accompanied by a bright vegetative reaction: sweating, a feeling of heat, fear.

The diagnosis of atrial flutter cannot be established only on the basis of the clinical picture. The decisive method for diagnosing this, like any other type of arrhythmia, is electrocardiography (ECG).

Diagnosis of atrial flutter.

Treatment of a permanent form of atrial fibrillation is carried out on the basis of data obtained after a comprehensive diagnosis. The exact cause is established using clinical, laboratory and instrumental studies. The main symptom that helps to suspect the disease is considered to be frequent and rhythmic pulsation in the veins of the neck.

It corresponds to atrial contractions of the myocardium, but exceeds the frequency in the peripheral arteries. There is a noticeable difference between the data obtained during the inspection. Additional methods include the following:

  • blood test for biochemistry;
  • INR level (international normalized ratio);
  • ECG (electrocardiography);
  • daily monitoring of ECG;
  • samples;
  • ultrasound examination of the heart (ultrasound);
  • transesophageal echocardiography.

To establish a diagnosis, unlike other pathologies, several diagnostic methods from the list indicated are enough. In complex cases, a more detailed examination may be required.

The main indicator, which is determined with a paroxysmal rhythm, is the level of lipids in the blood plasma. It belongs to one of the predisposing factors of atherosclerosis. The following data is important:

  • creatinine;
  • liver enzymes – ALT, AST, LDH, CPK;
  • plasma electrolytes – magnesium, sodium and potassium.

They must be taken into account before prescribing treatment to the patient. If necessary, the study is repeated.

For diagnosis, this indicator is very important. It reflects the state of the blood coagulation system. If there is a need for the appointment of “Warfarin” – it must be carried out. During the treatment of atrial fibrillation or flutter, the INR level should be monitored regularly.

With atrial fibrillation or flutter, even in the absence of a disease clinic, changes are detected on the electrocardiogram film. Instead of the P waves, pyloric teeth appear in leads I, III and avf. The frequency of the waves reaches 300 per minute. There are patients who have a permanent form of atrial fibrillation of an atypical nature. In this situation, such teeth will be positive on the film.

The study reveals an irregular rhythm, which is associated with impaired conduction of impulses through the atrioventricular node. There is also the opposite situation when normoform is observed. The pulse of such people is constantly within acceptable values.

In some cases, atriventricular blockade is found on the film of the electrocardiogram. There are several variations:

  • 1 degree;
  • 2 degree (includes 2 more types);
  • 3 degree.

When slowing down the conduction of nerve impulses through the pacemaker, the PR interval lengthens. Such changes are characteristic of blockade of the 1st degree. It appears in patients with constant treatment with certain drugs, damage to the myocardial conductive system or an increase in parasympathetic tone.

Divide the 2nd degree of violations into 2 types. The first is the Mobitz type, characterized by an elongated PR interval. In some cases, an impulse to the ventricles does not occur. When examining an electrocardiogram film, a QRS complex is detected.

Often there is type 2 with a sudden absence of a QRS complex. No extension of the PR interval is detected. With blockade of grade 3, there are no signs of nerve impulses on the ventricles. The rhythm slows down to 50 beats per minute.

This method for fibrillation or atrial flutter is considered one of the main instrumental. With its help, you can trace what changes occur during the work of the myocardium in various situations. During the day, tachysystole, blockade and other disorders are found.

The study is based on the registration of electrical activity in the process of the heart. All data is transferred to a portable device, which processes them into information in the form of a graphical curve. The electrocardiogram is stored on the device media.

For some patients, a cuff is additionally applied to the shoulder area when flickering. This allows you to control the dynamics of the level of blood pressure electronically.

A physical exercise test (treadmill test) or bicycle ergometry is indicated to the patient to determine cardiovascular system disorders. The duration of the study may vary. When unpleasant symptoms appear, it is stopped and the data obtained is evaluated.

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Signs of pathological changes in the heart are detected using ultrasound. The state of blood flow, pressure, valve apparatus, and the presence of blood clots are evaluated.

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Transesophageal Echocardiography

A special sensor for receiving data is inserted into the esophagus. When the patient has a constant form of fibrillation, atrial flutter, treatment should take about 2 days. For this reason, the main recommendation is to undergo therapy until normal rhythm is restored. The purpose of the instrumental study is to detect blood clots and assess the condition of the left atrium.

– An ECG is performed to determine arrhythmia.

– Holter monitoring allows you to determine paroxysmal atrial flutter, the causes of the attack, track the work of the heart during sleep and determine the strength of paroxysms.

– Ultrasound examination of the heart (echocardiography) allows you to determine the condition of the valves, contractile myocardial function and the size of the heart chambers.

– A blood test will help identify the cause of atrial flutter. For example, with potassium deficiency, thyroid dysfunction, and so on.

– In some cases, it is necessary to conduct an EFI (electrophysiological study) of the heart.

The treatment and secondary prophylaxis of atrial flutter, as well as the primary prophylaxis, practically does not differ from the treatment of atrial fibrillation. Comprehensive therapy is always carried out based on the elimination of the root cause of the development of atrial flutter and situations leading to paroxysms.

Drug treatment is prescribed exclusively by a doctor. You should especially be careful when stopping paroxysms and use only those medicines that the doctor prescribed.

The prognosis of treatment is generally similar to that of atrial fibrillation.

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Features of the treatment of persistent fibrillation in the elderly

Treatment of atrial flutter consists of actually stopping the disturbed rhythm and of preventing thromboembolic complications.

The following groups of drugs are used for drug antiarrhythmic therapy:

  • potassium channel blockers (cordaron, sotalol, ibutilide);
  • beta-blockers (talinolol, bisoprolol);
  • calcium channel inhibitors (verapamil)
  • cardiotonics (digoxin);

In emergency medicine, electric cardioversion is used to quickly normalize the rhythm. Due to the low-voltage current discharge, the effective functioning of the sinus node is restored.

If conservative therapy was ineffective, use surgical methods:

  • radiofrequency ablation (burning out ectopic foci of automatism using high-frequency current);
  • installation of a pacemaker (artificial pacemaker).

As in the previous case, it is necessary to treat both arrhythmias themselves and the prevention of thromboembolism. The specific scheme depends on the variant of rhythm failure and is decided by a hospital cardiologist.

Normosystolic is considered such a variant of atrial fibrillation, in which the normal frequency of contractions of the ventricles is maintained due to blockade in the AV node. It does not give visible hemodynamic disturbances and the general condition of the patient.

In this case, the patient does not need to receive any radical treatment, all that is needed is a dynamic observation by a cardiologist with the aim of early detection of complications.

If necessary, surgery is used, namely catheter or radio frequency ablation. Sometimes you may need to install a cardioverter.

Permanent type

The constant form of atrial fibrillation has the longest duration of the course, since its signs are absent or do not differ in significance. Also, this diagnosis is made when it is impossible to restore the normal rhythm.

Persistent form

The diagnosis is established when the flicker attack lasts more than 7 days and there is the opportunity to normalize the rhythm. To do this, use one of the types of cardioversion:

  • pharmacological – performed using antiarrhythmic drugs. Amiodarone or Novocainamide is used predominantly for this purpose;
  • surgical – is reproduced by radio frequency radiation or cryoablation.

In parallel, anticoagulant therapy is used (the same as with flutter).

It is a kind of pathology in which the rhythm can self-repair. The attack, as a rule, lasts from 30 seconds to 7 days. To stop paroxysm, the following algorithm is used:

  1. If the duration of the heart failure is less than 48 hours:
    • Amiodarone is a first-line drug for AF of any etiology;
    • Propafenone, Sotalol;
  2. If the attack lasts more than 2 days, add anticoagulant therapy:
    • warfarin;
    • heparin;
    • antiplatelet agents (clopidogrel, acetylsalicylic acid)

The treatment of the chronic form of atrial fibrillation is often complicated by the presence of many concomitant pathologies, in particular, we are talking about heart failure in the elderly. Since cardioversion in such patients worsens their prognosis for survival, the intervention is contraindicated in this category of patients. In these cases, a heart rate control strategy is used.

Doctors only achieve a decrease in heart rate to 110 or less, while fibrillation remains.

The protocol allows restoration of sinus rhythm only in the following cases:

  • unable to normalize heart rate;
  • manifestations of AF persist when the target frequency is reached;
  • there is a possibility in the future to maintain the correct rhythm.

Of great difficulty is the treatment of atrial fibrillation in the elderly and especially the chronic form. Atrial flutter is almost always corrected with the help of medications. After the diagnosis, drug therapy is started.

Treatment begins with an integrated approach, for this they include more than one remedy. Conservative therapy includes the following groups of drugs:

  • beta-blockers;
  • cardiac glycosides;
  • calcium ion blockers – Verapamil;
  • potassium preparations;
  • anticoagulants – “Heparin”, “Warfarin”;
  • antiarrhythmic drugs – “Ibutilide”, “Amiodarone”.

Together with antiarrhythmic drugs, beta-blockers, calcium channel blockers and glycosides are included in the scheme. This is done to prevent tachycardia in the ventricles. It can be triggered by an improvement in the conductivity of nerve impulses in a pacemaker.

In the presence of congenital anomalies, the listed funds are not used in people of young and older age. Normally, it is required to prescribe anticoaculants and drugs to eliminate arrhythmias. If there are no contraindications to alternative methods of treatment, then you can take herbal remedies. Before this, the patient must obtain consent to their appointment with his doctor.

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First aid

With a sharp appearance of signs of flutter or fibrillation in combination with hypotension, cerebral ischemia, cardioversion is indicated. It is carried out by an electric current of insignificant voltage. Antiarrhythmic drugs are injected into a vein at the same time. They increase the effectiveness of therapy.

If there is a risk of complications, then Amiodarone is required as a solution. In the absence of dynamics, cardiac glycosides are needed. When the sinus rhythm is not restored, following all the stages of the patient management scheme, electrical stimulation is indicated.

Separate tactics of managing patients with seizures, the duration of which takes 2 days, are distinguished. As he continues to persist, Amiodarone, Cordaron, Verapamil, and Disopyramides are indicated. To return the sinus rhythm, transesophageal stimulation of the myocardium is prescribed. When arrhythmia lasts more than 2 days, anticoagulants are administered before cardioversion.

Operative therapy

In the absence of effectiveness, ablation is prescribed for drug therapy. Other indications are frequent relapses and a persistent variant of arrhythmia. The prognosis after treatment is favorable for the patient’s life.

A special approach is needed in identifying Frederick’s syndrome. In history, it was first described in 1904. The disease is rare, but represents a great danger. It includes clinical and electrocardiographic changes of complete blockade together with cardiac fibrillation (or atrial flutter).

Pathology has a difference not only in manifestations. Drug treatment does not give a positive answer. The only way out is to establish an artificial pacemaker. It will generate, if necessary, an impulse of electricity.

When signs of arrhythmia appear, timely diagnosis is important. In patients, it is possible to normalize the work of the heart with medications. The advanced stage and the chronic course of the pathology is considered an indication for surgery.

The treatment of atrial flutter is generally similar to that of atrial fibrillation. Both drug and non-drug methods of cardioversion or restoration of normal heart rhythm are used, however, the effectiveness of these measures is different. The most important component of arrhythmia therapy is the prevention of thromboembolic complications.

In general, medical cardioversion is less effective for atrial flutter than for atrial fibrillation. Paroxysm of atrial flutter is best stopped with the help of electric pulse therapy or radiofrequency ablation.

If, for one reason or another, these procedures are not possible, then cardioversion is carried out using intravenous administration of ibutilide. Its effectiveness ranges from 38% to 76%, however, it is significantly greater than that of other widely used antiarrhythmics (amiodarone, sotalol and others).

Sinus rhythm is maintained using the same drugs that are used for atrial fibrillation. However, here, as well as with the constant form of atrial flutter, it is much more difficult to control heart rate. As a result of this, a combination of two or even three drugs is often required (beta-blocker, calcium channel blocker and digoxin).

Radiofrequency catheter ablation is highly effective for the treatment of typical atrial flutter: in 81-95% of cases, the procedure allows you to completely restore the sinus rhythm.

During the procedure, an electrode is passed to the arrhythmogenic area of ​​the myocardium through a blood vessel. An electric current is passed through it, causing the catheter and the affected area to heat. As a result, the arrhythmogenic focus is destroyed, the vicious circle of pathological arousal is broken, and the atrial flutter stops.

Radiofrequency ablation may be accompanied by unpleasant symptoms. Cryothermal ablation is a full-fledged alternative with the same effectiveness, but during its implementation painful sensations practically do not arise.

According to the LADIP study, the recurrence rate of atrial flutter after radiofrequency ablation was significantly lower than after drug-induced cardioversion with amiodarone — 4% versus 30%. This testifies in favor of the high efficiency of ablation for the final solution of the problem of atrial flutter.

How to get rid of a disease

An effective therapy has been developed to relieve atrial flutter, but this arrhythmia is difficult to completely cure – in many patients, paroxysms appear again. In such cases, radical treatment is used, which helps eliminate the disease permanently in 95% of cases.

It is also worth noting that in addition to treating arrhythmia itself, the underlying disease that contributed to its appearance is also treated.

Read more about the drug and non-drug treatment of atrial flutter itself.

  • Transesophageal electrocardiostimulation (NPES) – elimination of arrhythmias using a special pacemaker, which is inserted through the esophagus.
  • Electric cardioversion – restoration of the correct rhythm by applying an electric discharge to the region of the heart.

Beta blockers or calcium channel blockers can be prescribed to prevent a second attack.

To avoid blood clots, apply Warfarin or Aspirin.

Radical methods

If drug treatment does not help, and arrhythmia still recurs, radiofrequency ablation (destruction by radio frequencies) or cryoablation (destruction-freezing) of the pathways along which the pulse circulates during the attack is prescribed.

They also set a pacemaker that sets the heart to the correct rhythm.

Possible complications

The last two arrhythmias are very dangerous and can end fatally.

Atrial flutter impairs blood circulation (hemodynamics) in the coronary vessels, which entails insufficient blood supply to the myocardium. This can cause a myocardial infarction, heart attack, or sudden cardiac arrest.

Frequent seizures lead to the development of chronic heart failure.


If you have heart failure and have been prescribed diuretics, pay special attention to this item, since diuretics remove potassium from the body. But do not overdo it, since an excess of this element can also provoke problems with the cardiovascular system and the kidneys. Before correcting your diet, consult a specialist and, if possible, take a blood test for potassium.

The same rules apply to those who have already experienced such an unpleasant phenomenon as atrial flutter. If the attack has been successfully stopped, take all medicines prescribed by your doctor and follow preventive measures to prevent a relapse of the disease.

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Svetlana Borszavich

General practitioner, cardiologist, with active work in therapy, gastroenterology, cardiology, rheumatology, immunology with allergology.
Fluent in general clinical methods for the diagnosis and treatment of heart disease, as well as electrocardiography, echocardiography, monitoring of cholera on an ECG and daily monitoring of blood pressure.
The treatment complex developed by the author significantly helps with cerebrovascular injuries and metabolic disorders in the brain and vascular diseases: hypertension and complications caused by diabetes.
The author is a member of the European Society of Therapists, a regular participant in scientific conferences and congresses in the field of cardiology and general medicine. She has repeatedly participated in a research program at a private university in Japan in the field of reconstructive medicine.