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cardio.atrial_flutter.v1

Atrial flutter (typical and atypical)

cardiologyacutechronicadultacuteinpatientoutpatienttransition
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Atrial flutter dossier — phenotype-stepwise master ladder: typical CTI / atypical / unstable / post-cardiac-surgery / stable RVR. Typical CTI-dependent flutter is curable with ablation (>95% acute success — Calkins 2007 PMID 28506916); refer EP early. Ibutilide highly effective chemical CV for flutter (~60% conversion); 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 (PMID 38033089). Setting playbooks: ed / inpatient / icu / outpatient / transition (5). RxNav verification + engine-specific test batch deferred to next session. DEPTH-PASS-3 2026-05-26 (lane-E): +NMA +USPSTF +Cochrane +ICER stubs +decision thresholds, side-car at cardio.atrial_flutter.v1._depth-pass-3.md.

Entry points (5)

  • symptom
    Palpitations or fluttering sensation
    palpitations
  • symptom
    Dyspnea, fatigue, decreased exercise tolerance
    dyspnea_or_fatigue
  • symptom
    Syncope or pre-syncope
    syncope_presyncope
  • imaging
    Flutter on 12-lead ECG or telemetry
    flutter_on_ecg
  • history
    Recurrent flutter or post-AF ablation atypical flutter
    prior_flutter_or_AF

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    CHA2DS2-VASc + ablation candidacy
  • sbprequired
    vital • used at RED_FLAGS
    Hemodynamic instability triggers immediate cardioversion
  • hrrequired
    vital • used at CONTEXT
    RVR severity; rate-control target
  • tshrequired
    lab • used at INITIAL_WORKUP
    Thyrotoxic flutter; reversible cause
  • bmp_mgrequired
    lab • used at INITIAL_WORKUP
    K+/Mg correction for AAD safety; renal dosing of DOAC
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Anemia worsens RVR symptoms
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    DOAC dose; AAD dosing
  • bnp_or_ntprobnp
    lab • used at INITIAL_WORKUP
    Tachycardia-mediated cardiomyopathy assessment
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    Sawtooth waves; conduction ratio; QTc baseline
  • tterequired
    imaging • used at INITIAL_WORKUP
    Structural disease; LA size; EF; thrombus screen
  • tee_pre_cardioversion
    imaging • used at TREATMENT
    Required if cardioverting <48 h without 3-wk therapeutic AC unless TEE-guided
  • cha2ds2_vasc_factorsrequired
    history • used at RISK_STRATIFICATION
    AC indication; same as AF
  • bleeding_historyrequired
    history • used at RISK_STRATIFICATION
    HAS-BLED
  • prior_ablation_or_cardioversionrequired
    history • used at CONTEXT
    Recurrence pattern
  • current_medsrequired
    medication • used at CONTEXT
    AAD interactions, AVN-blocker review

12-phase flow (12)

  1. 1FRAME
    Confirm atrial flutter (sawtooth, atrial rate ~300, conduction ratio); typical (CTI) vs atypical (post-ablation, scar)
    inputs: ecg_12_lead
    advance: Flutter confirmed; type assigned
  2. 2ENTRY
    Palpitations / dyspnea / syncope / incidental telemetry
    inputs: age
    advance: Engine entered
  3. 3CONTEXT
    CV risk factors, structural heart disease, prior AC, prior cardioversion / ablation, alcohol / hyperthyroid / OSA, comorbidity
    inputs: hr, cha2ds2_vasc_factors, bleeding_history, prior_ablation_or_cardioversion, current_meds
    advance: Context complete
  4. 4RED_FLAGS
    Hemodynamic instability (SBP <90 / shock / pulmonary edema / ischemia / AMS) → DC cardioversion now
    inputs: sbp
    actions: tachycardia
    advance: Stable or cardioverted
  5. 5INITIAL_WORKUP
    ECG, TSH, BMP/Mg, CBC, creatinine, BNP, TTE
    inputs: ecg_12_lead, tsh, bmp_mg, cbc, creatinine_egfr, tte
    actions: panel.cardiac, panel.cbc, panel.thyroid, panel.renal
    advance: Stage-1 returned
  6. 6BRANCHING_WORKUP
    TEE if cardioversion needed <48 h without therapeutic AC; OSA workup if obese / nocturnal symptoms; Holter / loop recorder for paroxysmal
    inputs: tee_pre_cardioversion
    advance: Branch resolved
  7. 7DIFFERENTIAL
    Flutter vs AF vs SVT vs MAT vs sinus tachy with block
    advance: Diagnosis confirmed
  8. 8RISK_STRATIFICATION
    CHA2DS2-VASc (AC indication); HAS-BLED (bleed risk)
    inputs: cha2ds2_vasc_factors, bleeding_history
    actions: calc.cha2ds2vasc, calc.has_bled
    advance: Risk tier documented
  9. 9TREATMENT
    Unstable → DC cardioversion 50–100 J biphasic. Stable → rate (BB or non-DHP CCB) vs rhythm (ibutilide / dofetilide / amiodarone / DC cardioversion). AC per CHA2DS2-VASc same as AF. Long-term: CTI ablation curative for typical flutter.
    inputs: hr, creatinine_egfr, tee_pre_cardioversion
    advance: Strategy + AC + ablation referral plan documented
  10. 10DISPOSITION
    Admit if unstable / new HF / recent ablation / acute proarrhythmia; discharge if rate-controlled and AC plan started
    advance: Disposition documented
  11. 11MONITORING
    Telemetry, AAD QT (esp dofetilide/sotalol/ibutilide), DOAC/INR adherence, K/Mg
    inputs: ecg_12_lead
    advance: Monitoring orders documented
  12. 12FOLLOWUP
    EP referral for CTI ablation; cardiology q3–6 mo; chronic AC review; lifestyle (alcohol, weight, OSA)
    advance: Follow-up booked