ECG education

Atrial flutter in a 65-year-old woman with asthma

Vivienne Miller



Articles in this section are inspired by, but not based on, real cases to illustrate the importance of knowledge about ECGs in relation to clinical situations in general practice. Management is not discussed in detail.

Key Points

  • The normal atrial flutter rate is 250 to 320 bpm, usually 300 bpm, although it may be slower than this in patients on antiarrhythmic medications.
  • The AV node is not normally capable of conducting at this rate, so there is usually a 2:1 block or greater.
  • Typically, there are sawtooth flutter (F) waves on the ECG that are best seen in leads II, III, aVF and V1.
  • Elective electrophysiological study and catheter ablation of the re-entry circuit are an option as first-line management for appropriate patients who have atrial flutter.
  • Radiofrequency catheter ablation is superior to medication for controlling rhythm and rate and has a low incidence of side effects and complications.
  • Medications used for control of atrial flutter rate and/or rhythm include beta blockers, sotalol, diltiazem, verapamil, digoxin, flecainide and amiodarone.
  • Flecainide should not be used without concomitant AV nodal blocking drugs such as beta blockers or nondihydropyridine calcium antagonists as it may cause 1:1 conduction and cardiovascular collapse.
  • Re-anticoagulation, the patient’s risk of thromboembolism should be weighed against their bleeding risk.