Atrial Flutter

Atrial flutter is a common heart rhythm problem where your heart beats too fast in a regular pattern, caused by faulty electrical signals in your heart’s upper chambers. This condition can affect your heart’s efficiency and increase your risk of serious complications like stroke, but treatments including medications and procedures can help manage it effectively.

Table of contents

• What is Atrial Flutter?
• How the Heart’s Electrical System Works
• Types of Atrial Flutter
• Symptoms
• Causes and Risk Factors
• Complications
• Diagnosis
• Treatment
• Living with Atrial Flutter

What is Atrial Flutter?

Atrial flutter is a type of arrhythmia (abnormal heart rhythm) where your heart beats too fast. It is one of the most common heart rhythm problems people experience^[1]. In this condition, the upper chambers of your heart, called the atria, beat much faster than they should^[3].

A normal heart rate is 60 to 100 beats per minute when you’re at rest. With atrial flutter, your heart’s upper chambers can beat 250 to 350 times a minute. This causes your lower chambers, called the ventricles, to beat fast in response, commonly as fast as 150 beats a minute or more^[3].

Unlike some other heart rhythm problems where the heartbeat is irregular and chaotic, atrial flutter makes your heart beat in a fast but consistent pattern^[3]. This happens because of faulty electrical signals in your heart.

How the Heart’s Electrical System Works

Your heartbeat is controlled by an electrical system. Normally, electrical impulses are sent out from a natural pacemaker in your heart called the sinus node (or SA node), which is located in the right upper chamber of your heart. This node controls your heart rate and the timing of each heartbeat^[6].

The electrical impulses travel through the heart muscle in the atria, which triggers the muscle to squeeze and pump blood. When this system works properly, all the chambers of your heart work together smoothly to pump blood throughout your body^[7].

In atrial flutter, an abnormal electrical circuit forms in the atria. This new circuit creates abnormally frequent contractions in the upper chambers and takes over control of your heart rhythm and rate. It may cause the lower chambers of the heart to beat fast too, but often not as fast as the atria^[6].

Types of Atrial Flutter

There are different types of atrial flutter based on where the abnormal electrical signals occur and how they move through your heart^[3]:

• Typical atrial flutter (most common type): The abnormal electrical signals move in a counterclockwise circle in your right atrium. This is also called cavotricuspid isthmus-dependent flutter^[2].
• Reverse typical: The abnormal electrical signals move in a clockwise direction in your right atrium^[3].
• Atypical atrial flutter: This type is not common unless you’ve had heart surgery or other procedures before. The abnormal electrical signals can happen in your left or right atrium and are independent of the cavotricuspid isthmus^[3].

Your healthcare provider can tell which type you have based on the results of your electrocardiogram test.

Symptoms

Some people with atrial flutter don’t have any symptoms at all. The irregular heartbeat may be discovered during a health checkup for another reason^[1]. However, when symptoms do occur, they can include^[3]:

• A pounding, racing, or fluttering feeling in the chest (called palpitations)
• Shortness of breath
• Chest pain
• Dizziness or feeling lightheaded
• Feeling very tired or having a lack of energy (called fatigue)
• Fast pulse
• Fainting or almost fainting
• Swelling in your feet and legs if you have heart failure^[6]

Some people have no symptoms or only minor ones, especially if their heart rate is controlled and their heart otherwise works as it should^[6].

Causes and Risk Factors

Atrial flutter is caused by changes in your heart’s electrical system. The condition often happens after some types of heart surgery, heart muscle damage, or other changes to the heart^[6]. For the abnormal electrical circuit to form, certain elements must be present, including areas with fast and slow speeds of electrical conduction and different recovery periods^[2].

Your risk of developing atrial flutter increases as you get older. Men are also at higher risk than women^[3]. Several health conditions and factors can raise your risk^[6]:

• High blood pressure
• Heart valve disease
• Coronary artery disease (disease affecting the blood vessels that supply your heart)
• Heart failure
• Congenital heart disease (heart problems present from birth)
• Previous heart surgery
• Diabetes
• Lung disease
• Overactive thyroid (hyperthyroidism)
• Obesity
• Alcohol consumption
• Obstructive sleep apnea
• Overexercising, such as in endurance athletes
• Family history^[6]

Complications

When you have atrial flutter, your heart isn’t working as efficiently as it should. Think of blood flow through your heart like an assembly line, where blood moves from one chamber to the next before leaving your heart. Atrial flutter is like having the speed set too fast at the first station^[3].

Your heart’s chambers can’t fill with blood fast enough because the contractions are too frequent. There isn’t enough time for your atria to empty all their blood into your ventricles. This causes your heart to pump less blood to your body than it should^[3].

Some blood stays in your atria because there isn’t time for all of it to move out. Blood clots could form in blood that sits and pools. These clots can break free and travel to your brain, causing a stroke. They could also travel to other parts of your body and cause a heart attack^[3].

Over time, the fast pulse from atrial flutter can weaken your heart muscle, a condition called cardiomyopathy. When your heart beats too quickly for extended periods, your ventricles can’t fill with blood properly. Your heart pumps less blood, which can lead to heart failure^[3].

Diagnosis

To diagnose atrial flutter, a healthcare professional will examine you, listen to your heart, and take your blood pressure. You will usually be asked questions about your symptoms, health habits, and medical history^[11].

Several tests may be used to check your heart and look for conditions that can cause irregular heartbeat^[11]:

• Electrocardiogram (ECG or EKG): This quick test measures the electrical activity in your heart through small patches placed on your chest and sometimes your arms or legs. The patches connect to a machine that records your heart rate and rhythm. If you have atrial flutter, the lines on the graph will look like a sawtooth or picket fence pattern^[3].
• Holter monitor: This is a portable ECG device you can wear to record your heart rhythm for 24 hours or longer. Some models can be worn for several weeks^[6].
• Event monitor: This type of ECG samples your heart rate over several days to weeks. It can be hard to capture atrial flutter if it happens on and off or only lasts a few minutes. The longer the recording time, the higher the chance atrial flutter can be captured^[7].
• Implantable loop recorder: If irregular heartbeat symptoms don’t happen very often, this device may be surgically placed under the skin in your chest area. It constantly records your heart’s electrical activity and can stay in place for up to three years^[7].
• Echocardiogram: This test uses sound waves to take pictures of your beating heart. It shows the structure of your heart and heart valves, and how blood flows through your heart^[11].
• Blood and urine tests: These tests look for health conditions or substances that may affect your heart or heartbeat, such as checking your liver, thyroid, and kidney function^[11].

Treatment

The main goals of treatment for atrial flutter are to control your heart rate, restore a normal heart rhythm, prevent stroke, and help you feel better. Treatment choices depend mainly on how long you’ve had atrial flutter, how long it lasts, if a cause was found, your risk of stroke, and how much trouble your symptoms cause^[17].

Most often, treatment includes medicines that either keep your heart in a normal rhythm or keep your pulse at a normal rate (under 100 beats per minute) while the atria are in atrial flutter^[17].

Medications

Several types of medicines may be prescribed^[9]:

• Medicines to slow your heart rate: These help relieve your symptoms by controlling how fast your heart beats.
• Antiarrhythmic medicines: These can be taken as needed to stop an episode or taken every day to prevent future atrial flutter.
• Blood-thinning medicines (anticoagulants): These help prevent blood clots from forming in your heart, which reduces your risk of stroke. The most common one is warfarin. Other blood thinners that work as well as warfarin and have a lower risk of bleeding are also available^[17].

If you are prescribed warfarin, you will need regular blood tests (called INR) to make sure the dose is right for you. Aspirin also works as a blood thinner and is sometimes used for people who are at low risk of stroke^[17].

Electrical Cardioversion

If atrial flutter can’t be managed well with medicine, your doctor may recommend electrical cardioversion. This is an outpatient procedure where you’re put to sleep, and large electrode patches are placed on your chest and back. An electric current is sent through these patches as a shock that is synchronized with your heartbeat. In many cases, this restores a normal rhythm^[7].

Catheter Ablation

Catheter ablation is a procedure where thin wires are used to send energy to destroy the tiny areas of heart tissue that are causing atrial flutter^[9]. This procedure has a high success rate and low complication rate, making it superior to medical therapy for many people. In fact, catheter ablation can be considered as a first-line therapy in patients with typical atrial flutter if they are reasonable candidates^[14].

Successful ablation reduces or eliminates the need for long-term medicines and anticoagulation (unless you also have another heart rhythm problem called atrial fibrillation)^[14].

Timing and Anticoagulation

For atrial flutter lasting less than 48 hours, cardioversion can be attempted as soon as possible. For episodes lasting longer than 48 hours or of uncertain duration, anticoagulation therapy should be started. Rate control and therapeutic anticoagulation are required for a minimum of 4 weeks before cardioversion. Even after successful cardioversion, anticoagulation must continue for at least 4 weeks^[14].

Living with Atrial Flutter

With proper treatment and follow-up care, most people with atrial flutter are able to live full and active lives. Follow-up care is a key part of your treatment and safety^[20]. Several lifestyle changes and strategies can help you manage your condition better:

Take Your Medications Properly

Take your medicines exactly as prescribed. If your doctor has given you a blood thinner, be sure you understand how to take it safely, as blood thinners can cause serious bleeding problems. Don’t take any over-the-counter drugs or natural health products without talking to your doctor first^[20].

Adopt a Heart-Healthy Lifestyle

Several lifestyle changes can help protect your heart^[20]:

• Try to quit or cut back on using tobacco and other nicotine products, including smoking and vaping. Smoking can increase your chance of stroke and heart attack.
• Eat heart-healthy foods including vegetables, fruits, nuts, beans, lean meat, fish, and whole grains. Limit sodium and sugar.
• If you drink alcohol, try to drink less. Work with your doctor to find what is best for you.
• Stay at a weight that’s healthy for you.
• Try to get 7 to 9 hours of sleep each night.
• Manage other health problems such as high blood pressure, high cholesterol, and diabetes.

Stay Active Safely

Routine exercise is safe and helps you maintain and improve your heart health. Before starting an exercise routine, talk to your doctor about what type and level of exercise is safe for you. Try to be physically active for 30 minutes, 5 days a week. For many people, walking is a good choice^[20].

When you exercise, watch for signs that you’re pushing too hard. You are exercising too hard if you can’t talk while you exercise. If you become short of breath, dizzy, or have chest pain, sit down and rest right away^[20].

Prevent Infections

Get the flu vaccine every year and a pneumococcal vaccine shot. Stay up to date on your COVID-19 vaccines to help avoid infections^[20].

Regular Follow-up

Make and go to all appointments with your healthcare provider. Call if you’re having problems. Keep a list of the medicines you take and know your test results. Follow-ups are important because atrial flutter can keep coming back^[3].