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Atrial utter

2 Pathophysiology

Atrial utter (AFL) is an abnormal heart rhythm that


occurs in the atria of the heart.[1] When it rst occurs, it is usually associated with a fast heart rate or
tachycardia (beats over 100 per minute),[2] and falls into
the category of supra-ventricular tachycardias. While this
rhythm occurs most often in individuals with cardiovascular disease (e.g. hypertension, coronary artery disease,
and cardiomyopathy) and diabetes, it may occur spontaneously in people with otherwise normal hearts. It is typically not a stable rhythm, and frequently degenerates into
atrial brillation (AF). However, it does rarely persist for
months to years.

Atrial utter is caused by a reentrant rhythm in either


the right or left atrium. Typically initiated by a premature electrical impulse arising in the atria, atrial utter
is propagated due to dierences in refractory periods of
atrial tissue. This creates electrical activity that moves in
a localized self-perpetuating loop. For each cycle around
the loop, there results an electric impulse that propagates
through the atria.

The impact and symptoms of atrial utter depend on the


heart rate of the patient. Heart rate is a measure of the
Atrial utter was rst identied as an independent medical ventricular rather than atrial activity. Impulses from the
condition in 1920 by the British physician Sir Thomas atria are conducted to the ventricles through the atrioLewis (18811945) and colleagues.[3]
ventricular node. Due primarily to its longer refractory
period, the AV node exerts a protective eect on heart
rate by blocking atrial impulses in excess of about 180
beats/minute, for the example of a resting heart rate.
(This block is dependent on the age of the patient, and
can be calculated roughly by subtracting patient age from
220). If the utter rate is 300/minute only half of these
impulses will be conducted, giving a ventricular rate of
1 Signs and symptoms
150/minute, or a 2:1 heart block. The addition of ratecontrolling drugs or conduction system disease can increase this block substantially (see image below).
While atrial utter can sometimes go unnoticed, its onset is often marked by characteristic sensations of regular
palpitations. Such sensations usually last until the episode
3 Classication
resolves, or until the heart rate is controlled.
Atrial utter is usually well tolerated initially (a high heart
rate is for most people just a normal response to exercise),
however, people with other underlying heart disease or
poor exercise tolerance may rapidly develop symptoms,
which can include shortness of breath, chest pains, lightheadedness or dizziness, nausea and, in some patients,
nervousness and feelings of impending doom.

There are two types of atrial utter, the common type I


and rarer type II.[4] Most individuals with atrial utter will
manifest only one of these. Rarely someone may manifest
both types; however, they can only manifest one type at a
time.

3.1 Type I

Prolonged fast utter may lead to decompensation with


loss of normal heart function (heart failure). This may
manifest as eort intolerance (exertional breathlessness),
nocturnal breathlessness, or swelling of the legs or abdomen.

Type I atrial utter, also known as common atrial utter or typical atrial utter, has an atrial rate of 240 to
340 beats/minute. However, this rate may be slowed by
antiarrhythmic
agents.
Atrial utter is recognized on an electrocardiogram by
presence of characteristic utter waves at a regular rate of The reentrant loop circles the right atrium, passing
240 to 440 beats per minute. Individual utter waves may through the cavo-tricuspid isthmus - a body of brous tisbe symmetrical, resembling p-waves, or may be asym- sue in the lower atrium between the inferior vena cava,
metrical with a sawtooth shape, rising gradually and and the tricuspid valve. Type I utter is further divided
falling abruptly or vice versa. If atrial utter is suspected into two subtypes, known as counterclockwise atrial
clinically but is not clearly evident on ECG, acquiring a utter and clockwise atrial utter depending on the diLewis lead ECG may be helpful in revealing utter waves. rection of current passing through the loop.
1

5 COMPLICATIONS
is relatively resistant to chemical cardioversion, and often
deteriorates into atrial brillation prior to spontaneous return to sinus rhythm. Exact placement of the pads does
not appear important.[6]

4.2 Ablation

Type I atrial utter, counterclockwise rotation with 3:1 and 4:1


AV nodal block.

Because of the reentrant nature of atrial utter, it is often


possible to ablate the circuit that causes atrial utter. This
is done in the electrophysiology lab by causing a ridge of
scar tissue that crosses the path of the circuit that causes
atrial utter. Ablation of the isthmus, as discussed above,
is a common treatment for typical atrial utter.

Counterclockwise atrial utter (known as cephalad- 5 Complications


directed atrial utter) is more commonly seen. The
utter waves in this rhythm are inverted in ECG Although often regarded as a relatively benign rhythm
leads II, III, and aVF.
problem, atrial utter shares the same complications as
the related condition atrial brillation. There is paucity
The re-entry loop cycles in the opposite direction in
of published data directly comparing the two, but overall
clockwise atrial utter, thus the utter waves are upmortality in these conditions appears to be very similar.[7]
right in II, III, and aVF.
Catheter ablation of the isthmus is a procedure usually 5.1 Rate related
available in the electrophysiology laboratory. Eliminating
conduction through the isthmus prevents reentry, and if Rapid heart rates may produce signicant symptoms in
successful, prevents the recurrence of the atrial utter.
patients with pre-existing heart disease. Even in patients
whose hearts are normal to start with, prolonged tachycardia tends to produce ventricular decompensation and
3.2 Type II
heart failure.
Type II utter follows a signicantly dierent re-entry
pathway to type I utter, and is typically faster, usually 5.2 Clot formation
340-440 beats/minute.[5] Left atrial utter is common after incomplete left atrial ablation procedures.
Because there is little if any eective contraction of the
atria there is stasis (pooling) of blood in the atria. Stasis
of blood in susceptible individuals can lead to formation
4 Management
of thrombus (blood clots) within the heart. Thrombus is
most likely to form in the atrial appendages. Clot in the
In general, atrial utter should be managed the same as left atrial appendage is particularly important since the
atrial brillation. Because both rhythms can lead to the left side of the heart supplies blood to the entire body.
formation of thrombus in the atria, individuals with atrial Thus, any thrombus material that dislodges from this side
utter usually require some form of anticoagulation or of the heart can embolize to the brain, with the potentially
anti-platelet agent. Both rhythms can be associated with devastating consequence of a stroke. Thrombus material
dangerously fast heart rate and thus require medication can of course embolize to any other portion of the body,
for rate and or rhythm control. Additionally, there are though usually with a less severe outcome.
some specic considerations particular to treatment of
atrial utter.

5.3 Sudden cardiac death

4.1

Cardioversion

Atrial utter is considerably more sensitive to electrical


direct-current cardioversion than atrial brillation, and
usually requires a lower energy shock. 20-50J is commonly enough to revert to sinus rhythm. Conversely, it

Sudden death is not directly associated with atrial utter. However, in individuals with a pre-existing accessory
conduction pathway, such as the bundle of Kent in WolParkinson-White syndrome, the accessory pathway may
conduct activity from the atria to the ventricles at a rate
that the AV node would usually block. Bypassing the AV

3
node, the atrial rate of 300 beats/minute leads to a ventricular rate of 300 beats/minute (1:1 conduction). Even
if the ventricles are able to sustain a cardiac output at
such a high rates, 1:1 utter with time may degenerate
into ventricular brillation, causing hemodynamic collapse and death.

References

[1] Atrial utter at Mount Sinai Hospital


[2] "atrial utter" at Dorlands Medical Dictionary
[3] Lewis T, Feil HS, Stroud WD (1920). Observations
upon utter, brillation, II: the nature of auricular utter.
Heart 7: 191.
[4] Surawicz, Borys; Knilans, Timothy K.; Chou, Te-Chuan
(2001). Chous electrocardiography in clinical practice:
adult and pediatric. Philadelphia: Saunders. ISBN 07216-8697-4.
[5] Atrial Flutter: Overview - eMedicine Cardiology.
Archived from the original on 26 February 2009. Retrieved 2009-03-06.
[6] Kirkland, S; Stiell, I; AlShawabkeh, T; Campbell, S; Dickinson, G; Rowe, BH (July 2014). The ecacy of pad
placement for electrical cardioversion of atrial brillation/utter: a systematic review.. Academic emergency
medicine : ocial journal of the Society for Academic
Emergency Medicine 21 (7): 71726. PMID 25117151.
[7] Vidaillet H, Granada JF, Chyou PH, Maassen K, Ortiz M,
Pulido JN, et al., A Population-Based Study of Mortality among Patients with Atrial Fibrillation or Flutter The
American Journal of Medicine 2002 Oct 1;113(5):365-70.
PMID 12401530. doi:10.1016/S0002-9343(02)01253-6

7 TEXT AND IMAGE SOURCES, CONTRIBUTORS, AND LICENSES

Text and image sources, contributors, and licenses

7.1

Text

Atrial utter Source: http://en.wikipedia.org/wiki/Atrial%20flutter?oldid=638602624 Contributors: Rossumcapek, Hadal, Diberri, Exploding Boy, Ksheka, Jfdwol, St3vo, Hob, PFHLai, Rich Farmbrough, Shenme, Arcadian, Steveklein, Alansohn, Axl, Theodore Kloba,
Mauvila, Bsadowski1, Brighterorange, RobyWayne, YurikBot, Draeco, Mysid, Isaac elias, SmackBot, Bluebot, KieferSkunk, DRahier,
Dreadstar, Hu12, Thijs!bot, Powers.andy, Mikael Hggstrm, MoodyGroove, TXiKiBoT, Doc James, Toombes, Ddnile, Svick, PipepBot,
Arjayay, Rror, Addbot, CBHA, AkhtaBot, Bob K31416, Yobot, Gimrudghk, Piano non troppo, RadioBroadcast, Anna Frodesiak, Cannolis, GunnarK, Tocant, RedBot, DASHBot, John of Reading, WikitanvirBot, CornmealZeal, Jer5150, Jankaan, ClueBot NG, MrBill3,
EClop, Marine Corps Cadet, and Anonymous: 42

7.2

Images

File:AtrialFlutter12.JPG Source: http://upload.wikimedia.org/wikipedia/commons/8/86/AtrialFlutter12.JPG License: CC BY-SA 3.0


Contributors: Own work Original artist: James Heilman, MD

7.3

Content license

Creative Commons Attribution-Share Alike 3.0

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