Should patients receive anticoagulation for paroxysmal atrial flutter?

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.

A 57-year-old Caucasian female (CF) was admitted to the hospital with atrial flutter with rapid ventricular response (AFl-RVR). She was treated with diltiazem (Cardizem) IV, Cardizem drip and digoxin and converted to normal sinus rhythm (NSR).

Past medical history (PMH)

Hypertension (HTN), paroxysmal atrial fluttter (one episode 2 years ago), mild coronary artery diseases (CAD) (30% stenosis of LAD, RCA) diagnosed during left heart catheterization (LHC) 2 years ago, hyperlipidemia (HLP).

Medications

Lisinopril, ASA (aspirin), Lipitor (atorvastatin).

Allergies

None. She reports profound weakness and joint pain with beta-blockers.

Physical examination

Heart rate (HR) 165 bpm.
Cardiovascular system (CVS): Clear S1S2, irregularly irregular rhythm.
Chest: CTA (B).
Abdomen: Soft, NT, ND, +BS.
Extremities: no c/c/e.

What happened?

The patients converted to NSR, Cardizem drip was stopped and she is currently asymptomatic on oral Cardizem 30 mg po q 6 hr. TTE shows a normal ejection fraction and a moderate left atrial enlargement.

Should she receive anticoagulation for paroxysmal atrial flutter?

Yes. Patients with paroxysmal atrial fibrillation have a risk of thromboembolic complications probably equivalent to those with permanent atrial fibrillation.

The American College of Chest Physicians recommended that anticoagulation be considered for all patients with atrial fibrillation, whether it be chronic or paroxysmal (CCJM, 2000).

Anticoagulation with warfarin is recommended for all patients older than 75 years, as well as for patients younger than 75 years who have any of the following risk factors:

- Prior TIA, systemic embolus or stroke
- Hypertension
- Poor left ventricular function
- Rheumatic mitral valve disease
- Prosthetic heart valves

This is all correct but our patient has a paroxysmal atrial flutter. Do the same guidelines apply?

No prospective randomized studies are available to determine the incidence of thromboembolic complications in atrial flutter and the value of anticoagulant therapy. However, associated abnormalities are often present that favorthromboembolic complications such as valvular disease, hypertension, and heart failure. It is therefore advisable to anticoagulate the atrial flutter patients ( Circulation. 2002).

What happened next?

The patient was discharged home with Cardizem CD 120 mg po qd and Coumadin 5 mg po qd. Her INR was 1.5 at the time of discharge. She will have her INR checked on day 2 and 3 after discharge, and the laboratory will call her PCP to have the Coumadin dose adjusted to achieve INR level between 2 and 3. The patient's PCP was informed.

Final diagnosis

Paroxysmal atrial flutter.

What did we learn from this case?

Patients with paroxysmal atrial fibrillation/flutter have a risk of thromboembolic complications probably equivalent to those with permanent atrial fibrillation/flutter. The American College of Chest Physicians recommended thatanticoagulation be considered for all patients with atrial fibrillation/flutter, whether it be chronic or paroxysmal.

References

Should patients receive anticoagulation for paroxysmal atrial fibrillation? CCJM, 2000.
Indications for Anticoagulation in Atrial Fibrillation. AFP, 1998.
Anticoagulation therapy in paroxysmal atrial fibrillation. Tidsskr Nor Laegeforen. 2004 Apr 1;124(7):950-2.
Contemporary Management of Atrial Flutter. Circulation. 2002;106:649.
The Internists Approach to Atrial Fibrillation. Peter Holzberger, 2003. PowerPoint presentation, 1.3 mb.

Published: 07/21/2007
Updated: 07/21/2008

11 comments:

  1. Interesting case...thanks for sharing this!

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  2. Great info. Keep it up.

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  3. thanks for sharing!

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  4. I can appreciate this article in that it address Atrial Flutter patients being treated with anticoagulants, just as the Atrial fib patient is. We don't see as many cases of atrial flutter as afib on our unit. Thanks for that insightful information. I will be monitoring my patients discharge medication list for those with chronic or paroxysmal Afib/ Aflutter. Thanks again.

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  5. Since clinical exam of this patient showed irregularly irregular pulse,then she actually had atrial flutter fibrellation which is much the same like AFib, isn't it ?

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  6. Atrial flutter is different from atrial fibrillation. Not the same disease. The patients often fluctuate between flutter and fibrillation. Flutter is not a stable rhythm.

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  7. The final diagnosis was paroxysmal atrial flutter (AFl), in responding to proposed question of anti-coagulation requirements it would be interesting to determine the cause of the onset of AFl. Would it be appropriate to initiate

    C Mitchell

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  8. what is LAD and RCS???????????????

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  9. "what is LAD and RCS??" - Non-medical reader perhaps?

    left anterior descending (LAD)) artery
    http://en.wikipedia.org/wiki/Left_coronary_artery

    Right coronary artery (RCA)
    http://en.wikipedia.org/wiki/Right_coronary_artery

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  10. not non medical but 1st year student of mbbs

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  11. a case with past history of TIA one day ago with impaired LV function EF=38 that developed STROKE 2 dayes later because she was not anticaogulated even in sinus rhythm

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