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cardio.atrial_flutter.typical-cavotricuspid.v1

Typical (CTI-dependent) atrial flutter

cardiologyacutechronicadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.atrial_flutter.v1 — narrowed to typical CTI-dependent macroreentrant flutter (counterclockwise around tricuspid annulus, sawtooth negative II/III/aVF). Inherits AC + acute rate/rhythm management from parent; specializes the curative CTI ablation pathway (Class I ACC/AHA 2024) and post-procedure surveillance. CTI ablation curative for typical flutter with >95% acute success (Calkins 2007 PMID 17572388); Class I ACC/AHA 2024. Ibutilide ~60% chemical CV conversion for flutter (vs ~30% for AF); monitor QT 4 h post-dose for torsades. AC mirrors AF (CHA2DS2-VASc); 4-week post-CV AC mandatory regardless of score per ACC/AHA 2024 Class I. ~25% develop incident AF after successful CTI ablation — surveillance via outpatient Holter at 3/6/12 mo; route to cardio.afib.core.v1 if AF detected. Manifest pointer reuses cardio.atrial_flutter.v1 manifest. Design-brief pointer reuses parent. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute.

Entry points (3)

  • imaging
    Sawtooth flutter waves negative in II/III/aVF (counterclockwise CTI-dependent reentry)
    sawtooth_flutter_waves_inferior_negative
  • symptom
    Palpitations with regular narrow-complex tachy at HR ~150 (2:1 AV conduction signature)
    palpitations_with_regular_narrow_complex_150
  • history
    Recurrent typical flutter after prior cardioversion → CTI ablation candidate
    recurrent_typical_flutter_post_cv

Required inputs (9)

  • agerequired
    demographic • used at CONTEXT
    CHA2DS2-VASc + ablation candidacy
  • sbprequired
    vital • used at RED_FLAGS
    SBP <90 with flutter RVR → emergent DCCV (lower energy than AF, 50–100 J biphasic)
  • hrrequired
    vital • used at CONTEXT
    HR ~150 = pathognomonic 2:1 AV conduction in typical flutter; rate target 80–110
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    Negative sawtooth in II/III/aVF + positive in V1 confirms CTI-dependent counterclockwise circuit (Saoudi 2001 PMID 11428013)
  • tshrequired
    lab • used at INITIAL_WORKUP
    Thyrotoxic flutter — reversible cause; may not need ablation if TFTs normalize
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    DOAC dosing + contrast for ablation procedure
  • tterequired
    imaging • used at INITIAL_WORKUP
    LA size, EF, valvular disease — ablation safety + LV dysfunction screen
  • cha2ds2_vasc_factorsrequired
    history • used at RISK_STRATIFICATION
    AC indication identical to AF (Class I ACC/AHA 2024)
  • bleeding_historyrequired
    history • used at RISK_STRATIFICATION
    HAS-BLED + ablation peri-procedure bleed risk

12-phase flow (11)

  1. 1FRAME
    Confirm typical CTI-dependent flutter (sawtooth negative II/III/aVF, atrial ~300 bpm, ventricular often ~150 with 2:1) → curative ablation candidate per ACC/AHA 2024 Class I
    inputs: ecg_12_lead
    advance: Typical flutter morphology confirmed
  2. 2ENTRY
    Palpitations / dyspnea / fatigue / syncope / incidental ECG → typical flutter on 12-lead
    inputs: age
    advance: Engine entered
  3. 3CONTEXT
    Prior flutter / prior CV / prior ablation, CV risk factors, structural HD, alcohol / hyperthyroid / OSA, medication review (AAD, AVN blockers)
    inputs: hr, cha2ds2_vasc_factors, bleeding_history
    advance: Context complete
  4. 4RED_FLAGS
    Hemodynamic instability (SBP <90, pulmonary edema, ischemia, AMS) → synchronized DCCV 50–100 J biphasic now; flutter cardioverts at lower energy than AF
    inputs: sbp
    actions: tachycardia
    advance: Stable or cardioverted
  5. 5INITIAL_WORKUP
    ECG, TSH, BMP/Mg, creatinine, CBC, BNP, TTE — baseline + reversible-cause screen
    inputs: ecg_12_lead, tsh, creatinine_egfr, tte
    actions: panel.cardiac, panel.thyroid, panel.renal
    advance: Stage-1 returned
  6. 6BRANCHING_WORKUP
    TEE if cardioverting <48 h without therapeutic AC ≥3 wks; OSA evaluation if obese/nocturnal symptoms; chest-pain comorbid → acs_pathway
    actions: acs_pathway
    advance: Branch resolved
  7. 7RISK_STRATIFICATION
    CHA2DS2-VASc (AC indication identical to AF) + HAS-BLED + eGFR for DOAC dose
    inputs: cha2ds2_vasc_factors, bleeding_history
    advance: Risk tier documented
  8. 8TREATMENT
    Acute: rate control (BB or non-DHP CCB) ± chemical CV (ibutilide ~60% conversion) ± DCCV. Long-term: CTI ablation Class I (>95% acute success per Calkins 2007 PMID 17572388). AC same as AF; mandatory 4-week post-CV AC regardless of CHA2DS2-VASc.
    inputs: hr, creatinine_egfr
    advance: Acute strategy + AC + EP referral booked
  9. 9DISPOSITION
    Discharge if rate-controlled, AC initiated, EP referral booked; admit if unstable, new HF, AAD initiation, or post-ablation observation
    advance: Disposition documented
  10. 10MONITORING
    Telemetry post-CV; QTc post-ibutilide × 4 h; post-ablation observation for groin hematoma + tamponade; AC adherence
    inputs: ecg_12_lead
    advance: Monitoring orders documented
  11. 11FOLLOWUP
    EP for CTI ablation within 4–8 weeks (Class I); cardiology q3–6 mo; AC continuation per CHA2DS2-VASc; lifestyle (alcohol, weight, OSA); post-ablation 4-week ECG + Holter at 3 mo
    advance: Follow-up booked + ablation pathway entered