Atrial flutter


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Atrial flutter

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Atrial flutter


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Atrial flutter

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A 57-year-old male undergoes coronary artery bypass grafting due to severe symptomatic coronary artery disease. The surgery is uncomplicated, and the patient is admitted to the cardiothoracic intensive care unit for hemodynamic monitoring. Overnight, a rapid response is called after a tachyarrhythmia was noted on the patient’s telemetry strip. Temperature is 37.0°C (98.6°F), pulse is 140/min, respirations are 14/min, and blood pressure is 134/72 mmHg. He has incisional chest pain but is otherwise asymptomatic. The patient’s electrocardiogram is demonstrated below:  

Image reproduced from Wikimedia Commons  

Based on this patient's clinical presentation, which of the following is the most likely diagnosis?  

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Atrial flutter

β -blockers for p. 329

ECG tracing of p. 300

potassium channel blockers for p. 329


Content Reviewers

Rishi Desai, MD, MPH


Tanner Marshall, MS

Vincent Waldman, PhD

The heart has four chambers, two upper chambers—the left and right atrium, or together the atria, and two lower chambers—the left and right ventricles.

Atrial flutter is used to describe when the atria contract at really high rates—about 300 beats per minute, but sometimes as high as 400 beats per minute. Why flutter?

Well there’s a wave of muscle contraction that flows through the atria that looks like its flapping or fluttering, hence the name.

Normally, an electrical signal is sent out from the sinus node in the right atrium, but then propagates out through both atria super fast, causing the atria to contract.

Usually, that signal moves in one direction from the atria to the ventricles through the AV node, it then moves down to the ventricles, and causes them to contract shortly after.

After each ventricular contraction, the ventricle has to wait for another signal from the sinus node. With atrial flutter, a reentrant rhythm starts in either the right or left atrium.

Reentrant signals loop back on themselves, overriding the sinus node and setting up an endless cycle that causes the atria to contract again and again and again—at really fast rates.

There are actually two types, type 1 or typical atrial flutter is more common and is caused by a single reentrant circuit that moves around the annulus, or the ring of the tricuspid valve of the right atrium, usually in a counterclockwise direction when viewed looking up through the tricuspid valve.

Ok so imagine you’re this eyeball looking up through the valve, you’ll see the superior vena cava or SVC, the inferior vena cava or IVC, and the coronary sinus, or CS.

In this case, a stretch of tissue along the pathway called the cavotricuspid isthmus propagates the signal more slowly than the surrounding tissue.

Tissue that was just activated can’t be activated again until a certain amount of time has passed, which is called the refractory period; so that slow propagation gives the tissue enough time to be out of refractory, and therefore the circuit can loop on itself.


  1. "Robbins Basic Pathology" Elsevier (2017)
  2. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  3. "Pathophysiology of Disease: An Introduction to Clinical Medicine 8E" McGraw-Hill Education / Medical (2018)
  4. "Atrial flutter: more than just one of a kind" European Heart Journal (2015)
  5. "Typisches Vorhofflattern" Herzschrittmachertherapie + Elektrophysiologie (2016)
  6. "Atrial flutter" The Journal of Emergency Medicine (1988)

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