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Atrial Flutter


Atrial Flutter

This abnormal heart rhythm technically falls under the category of supra-ventricular tachycardias. Atrial flutter is typically not a stable rhythm and will frequently degenerate into atrial fibrillation.


Atrial Flutter will usually present with atrial rates between 240-350 beats per minute. These rapid atrial rates are caused by electrical activity that moves in a self-perpetuating loop within the atria.

The impact and symptoms of atrial flutter depend upon the ventricular rate of the patient (i.e. cardiac output). Usually, with atrial flutter, not all of the atrial impulses will be conducted to the ventricles, and the more atrial impulses that are conducted, the greater the negative effect.


Symptoms of atrial flutter are similar to those of atrial fibrillation and may include the following:

  • palpitations, chest pain or discomfort
  • shortness of air
  • lightheadedness or dizziness
  • nausea
  • nervousness and feelings of impending doom
  • symptoms of heart failure such as activity intolerance and swelling of the legs occur with prolonged fast flutter)


As with its symptoms, atrial flutter shares the same complications as atrial fibrillation. These complications are usually due to ineffective atrial contractions and rapid ventricular rates. Ineffective atrial contractions can lead to thrombus formation in the atria and rapid ventricular rates can cause decompensation and heart failure.

Prevent complications from atrial flutter with early cardioversion.


For the purposes of ACLS, atrial flutter is treated the same as atrial fibrillation. When atrial flutter produces hemodynamic instability and serious signs and symptoms, it is treated using ACLS protocol.

For the patient with unstable tachycardia due to this tachyarrhythmia (atrial flutter), immediate cardioversion is recommended. Drugs are not used to manage unstable tachycardia.


Atrial flutter is considerably more sensitive to electrical direct-current cardioversion than atrial fibrillation, and usually requires a lower energy shock. 20-50J is commonly enough to revert to sinus rhythm.

Below is a short video which will help you quickly identify atrial flutter on a monitor.
Please allow several seconds for the video to load.

  43 Responses to “Atrial Flutter”

  1. FYI on Chidi’s earlier comment.
    Objective assesment of Nigerian’s heath care delivery system show, there has not been a concerted effort to organize an effective Emergency response system. Emergency Medicine exist only in Teaching hospitals and few large hospitals in Abuja, Lagos and Port-harcourt.
    Therefore ACLS, ATLS and PALS are not emphasised tools of medical education for doctors even in very ‘sophisticated’ Hospitals.
    Nigeria is far behind Ghana, South Africa, Egypt and perhaps Morrocco in entrenching the modicum of quality emergency services.
    My experience is that doctors are still in ‘dark ages’ regarding these simple tools. A woman who collapsed in a bathroom, diaphoretic and hypotensive and obviously dypneic was given a ‘drip of Aminophylline and hydrocortisone, while an ER nurse was wrestling with the connectors of a nebulizer. This happened in the Emergency department of Umuahia ( A level 2 hospital by USA designation, and a teaching facility).
    I was so flabbergatsed when I was informed that the doctor put the cause of death as ‘Status Astmaticus’
    This happened to be my mum.
    She had TIA a year prior and was treated in USA. She had just gone down to Nigeria from USA for her grand daughters wedding.
    She obviously had either a PE or MI.
    She had been ‘embalmed by the time I flew back.
    No autopsy.
    there was no ECG done from my recollection, No CXR, No blood works (even if results came back post mortem)
    That is Nigeria.
    I am an ER physician, but in PEM.
    I am hoping as a 50th birthday gift next year to design an emergency response protocal for the same town my mother died and use it a pilot for the country. I am currently looking for volunteer Er physicians to laise with me to do the paperwork. And possibly visit (after the Ebola scare) hopefully in Oct 2015.
    Town population is maybe 1.5 million
    One large facility about 100 bed. They have 3 health centers with urgent care facilities
    They have oil money that can build an entire fleet of at least 10-15 equiped EMS ambulances and a dedicated emergency department built with a radio post.
    With 90% penetrance of cellular phones in the general population, the idea of training young intelligent men and women as EMTs will not be difficult. Also simultanously train trainers and Physicians (who ever work in their ERs).
    it is a dream.
    It will be worth my while, if I can get a financial backbone.

  2. I had been a cna, monitor tech and a nursing student. I also worked in a telemetry unit for over 5 years. though am in Africa at the moment, I really enjoyed the lessons and I miss working in the US so much. Nurses in Africa don’t have to go through ACLS. Can you guys imagine that?? Anyway, thank you so much Jeff. you are great. THANKS

    • So glad you are enjoying the site. Thanks for commenting. Kind regards, Jeff

    • CHIDI, if nurses in NIGERIA don’t go through ACLS, don’t say that nurses in Africa don’t do ACLS!
      NIGERIA IS NOT AFRICA ! Nigeria is just a country/state in Africa; and not an exemplary one for that matter.
      Just as US of America is NOT THE CONTINENTOF NORTH AMERICA. USA is not the only country in AMERICA.
      Travel to other AFRICAN countries – Egypt, South Africa, Morocco, Cameroun, Ethiopia, Ghana, etc; etc; and see what they are doing. Nursing is a universal science and abides to international standards.

      Jeff, your classes are appreciated and used all over AFRICA !
      Paul; RN.

      • Thank you Paul. That is the truth. ACLS is observed all over the world including NIGERIA. I don’t know where Chidi is speaking from. He really need to get more education about what he is talking about. Being a cna for several years and working in Tele unit for 5 years is not enough for Chidi to understand what ACLS entails.
        Thanks again.

        Pat. RN/BSN.

  3. what are F waves in atrial flutter? never heard of F waves before

    • Here is the medical dictionary definition for F waves.
      F-waves: A pattern of regular, rapid atrial waves in an electrocardiogram, indicative of atrial flutter.
      f-waves: A pattern of irregular undulations of the base line in an electrocardiogram that is indicative of atrial fibrillation.

      Kind regards,

      • This might make it a little more clear:
        With atrial flutter, P waves are replaced by “F” waves (saw tooth pattern in II, III, AVF)

        The F-waves are just a simple way to describe the 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.

        This is in contrast to the P-wave which is a single impulse that discharges in the atria and initiates the QRS complex.

  4. Hi, so if I noticed my stable pt had an atrial flutter rate in the high 200s and a vent.rate in the 70s, would I follow the Adult Tachycardia w/ pulse Algorithm (pg.118)?
    I see while traveling thru the Algorithm, I would end up at box 7 and if vagal maneuvers did not work, then Adenosine 6mg IV push would be given. Then I see on pg.165 under Adenosine Indications that: Adenosine does not convert atrial fibrillation, atrial flutter, or VT.
    How do I treat sawtooth atrial flutter or do I need a cardiologist?

    • If the ventricular rate was in the 70’s then this would not be tachycardia and it would not be treated with the adult tachycardia algorithm.

      If this was a new onset atrial flutter, you would want this patient to be admitted and consulted with a cardiologist.

      Now if you had atrial flutter with an atrial rate in the 200’s and the ventricular rate was around 120-180’s you would treat using the adult tachycardia algorithm and get a cardiologist to evaluate the patient as soon as possible.

      The ventricular rate is what determines if you progress into the use of the tachycardia algorithm.

      Kind regards,

  5. 100% HELPFUL, making ACLS as easy as learning ABC

  6. Thanks So Much. Trained as RN in early 60’s before nurses learned much cardiac info. I am learning so much & it’s enjoyable.

  7. sometimes i have a hard time differentiating between afib and aflutter. can you help?

    • Atrial FIBRILLATION, you will not see any p-waves. You may some a wavy line, but you should not see anything that resembles a consistent wave.
      Atrial FLUTTER, you will see some characteristic flutter waves at a regular rate of 240 to 440 beats per minute. Individual flutter waves may be symmetrical, resembling p-waves, or may be asymmetrical with a “sawtooth” shape, rising gradually and falling abruptly or vice versa.
      Kind regards,

  8. I have been detected atrial flutter. My P wave is 200 ventricular rate is 73 BPM. For last one month I am on Amiodarone Therapy(200mg * 3 times a day) with Aspirin(150 mg Delayed release once a day). My doctor says he will try me more 3 months on same therapy. If changes doesnot arise , he will see further. I consulted another Cardiac Electrophysiolist and he suggested me for an Ablation Therapy. By the way I am 30 years male. I am bit afraid of operation. Kindly suggest.

    • The question is really out of my scope of practice. I would get as many educated opinions as possible and then make the decision. I have seen both ablation therapy used and both at times with good effect. If you would like my personal opinion, I can give that. I personally am not one for long term medication use and I would look at all of the aspects of ablation therapy and speak with a couple of specialists about its effectiveness. I would also try and figure out what the underlying cause of the atrial flutter is. In other words, is there anything in your diet like caffeine or other stimulants that could be the cause of the cardiac irritability.
      I know a physician who has the same thing and he quit coffee and his problem went away.

      I hope this helps.
      I will pray for you.

      Blessings to you in Jesus name,

  9. Jeff the video talks of F waves? please explain what this means? That throws me a bit just want rationale and meaning to keep it clear in my head! Thanks for your help VickiBuz

  10. What are the chances of the formation of thrombus in the atrial cavity in the case of long standing atrial flutter? Do we have to give anti-coagulation, as in atrial fibrillation, to minimise the risk of emboli?

    • The chances for thrombus formation are relatively high. You would want to perform a TEE to ensure that there is no thrombus formation and you would want to initiate anti-coagulation therapy.
      Kind regards,

  11. stated that atrial flutter if stable…does not need to be treated? how long can you have this
    rythm and be stable?

    • Some people live with atrial flutter without any symptoms, but they have to be on anticoagulants to prevent blood clots from forming in the atria. If patients do have regular symptoms or if the atrial flutter affects activities of daily living cardioversion can be attempted to stop the flutter. Also some people opt. for cardiac ablation (cauterization of cardiac nerves). This intervention do not always work, but many do experience relief from the atrial flutter.
      Kind regards,

  12. You said that in unstable tachycardia drugs are not used to manage it, in the tachycardia algorighm if tachycardia caused symptoms adenosine may be used. I am confused.

    • I am assuming that “it” in your question is Unstable Tachycardia. Tachycardia with symptoms is not always the same as unstable tachycardia. For instance. You could have supraventricular tachycardia with a fluttering feeling and intermittent light dizziness. The fluttering feeling and light dizziness are symptoms with being unstable. Supraventricular Tachycardia with a fluttering feeling and light dizziness could be treated with adenosine if vagal maneuvers were not effective.
      Now if you have a Supraventricular tachycardia that is causing chest pain, hypotension (SBP<90), the symptoms indicate that the patient is unstable and you would want to use immediate cardioversion not adenosine.
      Kind regards, Jeff

    • I’m also confused about why it says drugs are not used in unstable tachycardia.
      Can someone please explain if this is true or it’s a typo.

      • Tachycardia with symptoms is not always the same as unstable tachycardia. For instance. You could have supraventricular tachycardia with a fluttering feeling and intermittent light dizziness. The fluttering feeling and light dizziness are symptoms without being unstable. Supraventricular Tachycardia with a fluttering feeling and light dizziness could be treated with adenosine if vagal maneuvers were not effective.
        Now if you have a Supraventricular tachycardia that is causing chest pain, hypotension (SBP<90), the symptoms indicate that the patient is unstable and you would want to use immediate cardioversion not adenosine.

        Unstable tachycardia means that the tachycardia is affecting blood perfusion and circulation. If the circulation is poor how will drugs be fully effective until you reestablish proper perfusion by the use of cardioversion. Therefore, Cardioversion is the primary treatment for unstable tachycardia.

        Kind regards, Jeff

  13. Thanks Jeff. Very informative

  14. I would assume that atrial flutter always has a rate in excess of 240. Are there any other rhythms that have rates that high? If not that might be one way to help identify flutter when not a saw tooth pattern.

    • Atrial flutter does not always have such a atrial rate, but it usually will. Remember flutter will many times only effect the atrial rate.

      The ventricular rate may still be relatively low but usually in excess of 100. Symptoms will be seen when the ventricular rate is affected or if the patient develops a blood clot due to the pooling of blood in the atria related to the ineffective fluttering.

      VT can have rates in excess of 240 but in this situation, the patient will most likely be pulseless and you will treat with the pulseless arrest algorithm.

      Usually you will recognize atrial flutter by consistent saw-tooth or wave-like pattern between the QRS complexes.

      Kind regards,

      • so, now that atrial rate is mentioned, i just want to have a clearer and deeper understanding on atrial rate in relation to ventricular rate, and flutter against fibrillation..the heart rate that is displayed on the monitor reflects the ventricular rate? or atrial? or both?.im sorry, but i got confused since atrial rate was mentioned.

      • It not as complicated as it seems. In the normal heart, the atrial rate is a result of the firing of the SA node which communicates with the AV node and then causes ventricular contraction. So in the normal heart, the atrial rate should equal the ventricular rate. P-wave is the representation of the atrial rate and the QRS is the representation of the ventricular rate.
        When the SA node is not firing properly you can have a very rapid atrial rate which wil usually result more p-waves that normal and there will be more p-waves than for each QRS wave. This usually presents as atrial flutter. Sometimes the AV node does not conduct every normal p-wave (it is blocked). This is where we see the different blocks like 1st, 2nd, and 3rd, degree block.
        Regarding ventricular issues, you can have ventricular arrhythmias that fire from the ventricular tissue rather than traveling through the normal pathways of the AV node. This is called VT and it can be quite deadly and it can quickly diminish oxygenation to the heart and lead to VF.
        To recap, when you see p-waves, you are looking at the electrical activity in the atria. When you see the QRS waves, you are looking at the electrical activity in the ventricles.
        Kind regards,

    • bglazer- One thing with A-flutter is that it can also be measured in an atrial/ventricular ratio. Ie. 2:1, 3:1, ect. So this means that a 3:1 will have 3 flutter waves with one ventricular contraction. Some of the times with low ratio flutters with rapid ventricular response is that it can be very difficult to recognize and sometimes will look like a normal tachydysrrhythmia which in this case will be treated based on the ‘stable’, ‘unstable’ principle.

  15. Just for my own clarity……energy levels for cardioversion of unstable a-flutter with both biphasic and monophasic devices? I haven’t seen anything as low as 20-50 joules mentioned in the AHA material, but I’m just getting started.

    Really appreciate this site!


    • Unstable atrial flutter would be treated as an unstable tachycardia within the tachycardia algorithm. Synchronized cardioversion would be indicated and the starting dose for narrow regular tachycardia would be 50 J. See pg. 118 of the AHA ACLS provider manual in the gray box to the right.
      The page which states that 20-50 J can be used for the conversion of atrial flutter is speaking about atrial flutter in general and this could mean both stable and unstable atrial flutter.
      Studies have shown that lower doses between 20-50 J are adequate for the conversion of atrial flutter.
      Kind regards,

  16. Love this. You make learning acls easy

  17. Is clotting an issue in atrial flutter?

  18. Excelent! ! !

  19. So helpful!

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