Patient handout

Atrial flutter with concurrent acute pulmonary embolism

PRODUCTION

1. Your condition

This handout is for atrial flutter with concurrent acute pulmonary embolism. Your care team identified this based on: atrial flutter on monitor + acute dyspnea / pleuritic chest pain / unexplained tachycardia → ct-pa to evaluate concurrent pe.

Other reasons your team may use this plan: ct-pa confirmed pe in patient with atrial flutter on telemetry — composite event; new afl on ecg with rv strain pattern (s1q3t3, t-wave inversions v1-v4, rbbb) → stat ct-pa; syncope or pre-syncope in patient with known afl — exclude massive pe before attributing to rvr.

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
alteplase	100 mg IV over 2 h (or 0.5 mg/kg over 15 min if PE-related cardiac arrest); UFH bridge 60 U/kg bolus then 12 U/kg/h to PTT 1.5–2× control	IV	one-time infusion	Massive PE Class I (ESC 2019 PMID 31504429); reduces in-hospital mortality; major bleed ~10%; intracranial hemorrhage ~2%
tenecteplase	30–50 mg IV bolus weight-based (60 kg <30 mg, 60–70 kg 35 mg, 70–80 kg 40 mg, 80–90 kg 45 mg, ≥90 kg 50 mg); UFH bridge	IV	single bolus	PEITHO (Meyer NEJM 2014 PMID 24716683) — single bolus convenience; sub-massive PE Class IIa risk-benefit individualized given bleed risk
unfractionated_heparin	60 U/kg IV bolus (max 5000 U) → 12 U/kg/h infusion (max 1000 U/h); titrate to PTT 1.5–2× control or anti-Xa 0.3–0.7	IV	bolus + continuous	Initial AC for massive/sub-massive PE; preferred over LMWH given thrombolysis option + reversibility — ESC 2019 (PMID 31504429)
enoxaparin	1 mg/kg SC q12h (1.5 mg/kg q24h alternative); 1 mg/kg q24h if CrCl 15–30	SC	BID	LMWH preferred for low/intermediate-risk PE without thrombolysis plan — ESC 2019; weight-based monitoring not routinely needed
apixaban	10 mg BID × 7 days → 5 mg BID maintenance (covers both AFL stroke prevention + PE treatment at single dose; 2.5 mg BID for AFL component if 2 of: ≥80 yr, ≤60 kg, Cr ≥1.5 — but maintain full 5 mg BID for first 6 mo to cover PE)	PO	BID	AMPLIFY (Agnelli NEJM 2013 PMID 23808982) for VTE; ARISTOTLE (PMID 21870978) for AF; single dose covers both indications
rivaroxaban	15 mg BID × 21 days → 20 mg daily with food (15 mg daily if CrCl 15–50)	PO	BID then daily	EINSTEIN-PE (Buller NEJM 2012 PMID 22449293) for VTE; ROCKET-AF (PMID 21830957) for AF; loading-dose pattern covers acute PE phase
dabigatran	150 mg BID after 5–10 days of parenteral AC (UFH or LMWH); avoid CrCl <30	PO	BID	RE-COVER (Schulman NEJM 2009 PMID 19966341) for VTE; requires 5–10 d parenteral lead-in (not direct-start like apixaban/rivaroxaban)
edoxaban	60 mg daily after 5–10 days of parenteral AC (30 mg if CrCl 15–50, ≤60 kg, or P-gp inhibitor)	PO	once daily	HOKUSAI-VTE (Buller NEJM 2013 PMID 23991658); requires parenteral lead-in
warfarin	5 mg daily; INR target 2–3; bridge with UFH/LMWH until therapeutic ×24h	PO	daily	Mechanical valve, severe MS, triple-positive APS, severe CKD → warfarin only — ACC/AHA 2024 (PMID 38753446)
metoprolol_tartrate	REDUCED DOSE: 2.5 mg IV initially (NOT full 5 mg q5min × 3); reassess RV/SBP/lactate before each subsequent dose; PO 12.5 mg BID start, titrate cautiously	IV/PO	reduced cadence; per RV tolerance	AVN slowing for AFL but RV-failure risk in PE — start LOW dose, monitor SBP + lactate + RV echo; AVOID if SBP <100 or echo shows RV strain progression — ESC 2019 (PMID 31504429); ACC/AHA 2024 (PMID 38753446)
diltiazem	REDUCED DOSE: 0.15 mg/kg IV (NOT full 0.25 mg/kg) over 2 min; infusion 5 mg/h start (NOT 10–15); avoid if SBP <100 or RV failure progression	IV/PO	reduced cadence	AVN slowing alternative; AVOID full doses given negative inotropic effect on already-strained RV; AVOID in HFrEF; ESC 2019 (PMID 31504429)

Plan: Atrial flutter + acute PE — PE-severity-tiered reperfusion + RV-protective rate control + dual-indication AC pathway — ESC 2019 PE (PMID 31504429) + ACC/AHA 2024 AF (PMID 38753446) + PEITHO (PMID 24716683)

3. When to call your provider

Contact your care team if any of the following happen:

Recurrent PE despite AC → re-evaluate, consider IVC filter or agent switch
Major bleed on AC → hold + reverse + reassess long-term strategy (LAA occlusion candidacy)
CTEPH progression → pulmonary endarterectomy referral + riociguat
New AF detected — same AC strategy already in place

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Massive PE with SBP <90 + RV failure on echo (McConnell sign, septal flattening, dilated IVC, TAPSE <16) + lactate ≥2 — Class I systemic thrombolysis(life-threatening)
AFL rate control attempted with BB or non-DHP CCB precipitates RV failure progression (worsening hypotension, rising lactate, declining TAPSE) — iatrogenic decompensation(life-threatening)
New focal neuro deficit during PE workup or treatment + bubble study positive for PFO with right-to-left shunt — paradoxical embolism causing stroke(life-threatening)
Major bleeding (intracranial, GI requiring transfusion, retroperitoneal, hemodynamic compromise) on AC for dual AFL+PE indication(life-threatening)
PEA arrest during AFL workup with high suspicion or confirmed PE — high-mortality presentation(life-threatening)

5. Follow-up

Pulmonology + cardiology + EP for AFL ablation candidacy; 3-mo follow-up echo for CTEPH screen (~3% incidence post-PE); thrombophilia workup if unprovoked PE + age <50; lifelong DOAC if AFL persistent or unprovoked PE; CTI ablation for typical AFL; pulmonary rehab

6. Sources

Guideline: 2024 ACC/AHA/ACCP/HRS AF + AFL Joint Guideline (Joglar PMID 38753446) + ESC 2019 Acute PE Guideline (Konstantinides PMID 31504429)