ATRIAL FLUTTER

Atrial rate >250 beats/minute with no flat baseline.

Can be difficult to recognize if 2:1 atrioventricular (AV) block, as the first of the 2 p waves preceding each QRS complex might be confused with the twelve of the preceding beat. Vagal stimulation might slow the ventricular rate and make the dysrhythmia more obvious.

GENERAL MEASURES

Synchronized DC cardioversion, 200 J, after sedation with:

•     Diazepam, IV, 10–20 mg.

If flutter has been present longer than 48 hours, defer cardioversion until after 4 weeks’ anticoagulation with warfarin, unless severe symptoms or heart failure require urgent cardioversion.

MEDICINE TREATMENT

DC cardioversion is the most effective therapy.

Do not use verapamil as it will not convert flutter to sinus rhythm and may cause serious hypotension.

Anticoagulants if sustained.

Long-term therapy

Recurrent atrial flutter is an indication for referral as some may be cured by radio-frequency catheter ablation.