Supraventricular Arrhythmias, Part II: Atrial Flutter and Atrial Fibrillation

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Chapter 15 Supraventricular Arrhythmias, Part II Atrial Flutter and Atrial Fibrillation

Please go to for supplemental chapter material.

The supraventricular (common narrow complex) tachycardias discussed so far have organized atrial activity (manifest by discrete P waves) and, with some notable exceptions, 1:1 atrioventricular (AV) conduction. Atrial fibrillation (AF) and atrial flutter (AFL) are two related (and sometimes missed or mistaken) arrhythmias with very rapid atrial rates that greatly exceed the ventricular rate (Fig. 15-1). This finding implies that some degree of physiologic (functional) AV block is almost always present. Furthermore, both arrhythmias involve reentrant mechanisms with impulses rapidly and continuously spinning around, “chasing their tails,” in the atrial muscle itself (see Fig. 15-1). Therefore, instead of true P waves, one sees continuous F (flutter) or f (fibrillatory) waves.

Atrial Flutter

Location of Conduction Pathways

The reentrant circuit of “typical” atrial flutter revolves around the tricuspid valve in the right atrium. Like reentrant supraventricular arrhythmias in general, it is initiated by a premature atrial complex (PAC) that blocks in one direction, while propagating in another. The signal then keeps circling in the same trajectory over and over again. In atrial flutter the typical frequency is about 300 cycles per minute (which is determined by the atrial size and conduction velocity) producing identical F waves.

The “bottleneck” where the signal usually blocks is the relatively narrow area between the tricuspid valve and inferior vena cava at the bottom of the right atrium (cavo-tricuspid isthmus). Conduction of the initiating PAC is blocked from propagating from the middle area of the right atrium to its lateral wall through this narrow isthmus. However, the electrical signal can propagate through the rest of the atrium and reach the isthmus from the other side. By this time the isthmus tissue has already recovered electrically and is ready to conduct. The signal goes through the isthmus in a counterclockwise direction, and the large (macro-) reentrant cycle starts again.

The classic “sawtooth” pattern of F waves that are predominantly negative in leads II, III, and aVF and positive in V1 with a very regular ventricular (QRS) rate of about 150/min (functional 2:1 AV block) is suggestive of the counterclockwise (common) type of typical right atrial flutter (Fig. 15-2A). Less frequently the same circuit gets initiated in the opposite direction, producing “clockwise” flutter. The polarity of the F waves will then be reversed: positive in leads II, III, and aVF, and negative in lead V1 (Fig. 15-2B). Clockwise and counterclockwise flutter can occur in the same patient and both are usually isthmus-dependent. Clinically, the development of atrial flutter most often indicates the presence of underlying structural/electrical atrial disease.

Conduction to the Ventricles

The atrial rate during typical atrial flutter, as noted, is around 300 cycles/min (range usually between about 240 to 330 cycles/min). Slower rates can be due to drugs that slow atrial conduction. Fortunately, the AV node cannot conduct electrical signals at that rate to the ventricles—although a bypass tract in the Wolff-Parkinson-White (WPW) syndrome (see Chapter 12) can! Thus, with atrial flutter, physiologic AV block develops (usually with a 2:1 A/V ratio) (Figs. 15-2 and 15-3). In the presence of high vagal tone, AV nodal disease, or AV nodal blocking drugs (e.g., beta blockers, digoxin, and certain calcium channel antagonists) higher degrees of AV block can be seen, for example with a 4:1 conduction ratio (Figs. 15-3 and 15-4).

Often the AV nodal conduction shows more complex patterns and the degree of AV block varies in a periodic way, producing flutter/QRS ratios with repeating patterns (Fig. 15-4) of RR intervals (group beating). This phenomenon is believed to be due to multiple levels of block within the conduction system. Variable AV block may be due to other mechanisms (e.g., AV Wenckebach) and produce noninteger ratios of F waves to QRS complexes (Fig. 15-5).

On the other hand, atrial flutter with 1:1 AV conduction (Fig. 15-6), although uncommon, can occur in three major settings:

Atrial flutter with sustained 1:1 AV conduction represents an emergency situation, requiring consideration of immediate synchronized electrical cardioversion because of the dangerously rapid ventricular rate.

Atrial Fibrillation

Unlike atrial flutter, the reentrant waves of atrial fibrillation (AF) cannot be localized to any repetitive and stable circuit in the atria. Most cases of AF are thought to originate in the area of pulmonary vein–left atrial junctions. With time, more and more of the atrial tissue becomes involved in the active maintenance of the arrhythmia, associated with the simultaneous formation of multiple unstable reentrant circuits throughout the atria (see Fig 15-1).

Atrial electrical activity on the ECG appears as irregular f (fibrillatory) waves, varying continuously in amplitude, polarity (reversing from positive or negative orientation in same lead), and frequency (changing cycle length, measured as the very brief interval from one f wave to the next).

Milder degrees of atrial activity “disorganization” or drugs that slow atrial activation may produce coarse AF with high amplitude f waves resembling atrial flutter (Fig. 15-7).