Figure 1 demonstrates atrial flutter with variable AV block. The work-up for an otherwise asymptomatic individual with rate-controlled atrial flutter is the same as that for atrial fibrillation (AF) and should be done in the outpatient setting. Indications for admission include significant symptoms (eg, angina, heart failure, onset of a thromboembolic process), hemodynamic instability, or evidence of ischemic changes on the ECG. Administering aspirin or a ß-blocker would not be appropriate in the absence of ischemic symptoms or ECG changes. Adenosine may prolong the AV block and make the flutter waves easier to see, but it will not convert flutter to sinus rhythm and is not needed to make the diagnosis in this case. Electrical cardioversion should not be performed at this time because the duration of the flutter is unclear; it could be done safely after TEE demonstrates the absence of atrial thrombus.
In the absence of symptoms or a difficult-to-
control heart rate, immediate cardioversion would not provide any significant benefit. AF and atrial flutter can be caused by ischemia, but without symptoms or ECG changes an ischemic evaluation is not indicated.1
- No immediate intervention is necessary; proceed with further evaluation as an outpatient.
1. Fuster V, Rydén LE, Cannom DS, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillationexecutive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation) [published erratum appears in J Am Coll Cardiol 2007;50:562]. J Am Coll Cardiol 2006;48:854-906.
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