Slide 1: 60-year-old female presents with palpitations! What is concerning about this EKG?

Slide 2: This is typical atrial flutter, a type of supraventricular tachycardia! One. “Sawtooth” pattern of flutter waves in inferior leads. “Slow down” and “fast up.” Loss of isoelectric baseline.

Two. Atrial activity/P-waves at 250-350 bpm.

Three. Upright flutter waves in V1.

Four. Narrow complex (QRS < 120 ms) tachycardia. What is the ratio between flutter waves and QRS complexes? This patient has "variable conduction with sometimes 4:1, 3:1, or 2:1 conduction. Slide 3: Pathophysiology of Typical Atrial Flutter. A macro re-entrant circuit in the right atrium. Travels through the cavotricupsid isthmus (CTI). Fibrous tissue between the IVC and tricupsid. Note! CTI is amenable to ablation. Look for triggers. Think PIRATES! Pulmonary (COPD, OSA, PE, etc.). Ischemia/Infarction. Rheumatic heart disease/Regurgitation (heart valves). Alcohol/Anemia. Thyrotoxicosis/Toxins (alcohol, drugs). Electrolyte abnormalities. Sepsis/surgery/stress. Slide 4: Management. One. Symptom Control. Atrioventricular (AV) node blockers. Beta blockers. Calcium channel blockers. Long-term management typically involves rhythm control with radiofrequency catheter ablation given the high rates of success. Two. Anticoagulation. To reduce the risk of thrombolization, use anticoagulation for CHA2DS2VASC >= 2. Anticoagulate all patients for 4 weeks after ablation or cardioversion. If concomitant atrial fibrillation, indefinite anticoagulation even if atrial flutter is ablated.

Slide 5: Atrial flutter takeaways. “Sawtooth” flutter at 250-300 bpm seen best in leads II, III, and aVF. A heart rate of 130-150 bpm is suspicious for atrial flutter with 2:1 conduction. Management: symptom control with AV node blocking agents. Rhythm control (including cardioversion or ablation). Anticoagulation. Typically due to re-entrant circuit in the right atrim. Anatomically easy to treat with ablation.

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