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cardio.atrial_flutter.with-stroke.v1

Atrial flutter complicated by acute embolic stroke

cardiologyacuteadultacuteinpatienttransitionoutpatient
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Phase E variant of cardio.atrial_flutter.v1 — composite cardioembolic ischemic stroke + new-or-known atrial flutter. Inherits AC + acute rate/rhythm management from parent; specializes the AC-timing dilemma (1–14 d delay per infarct size, NO LMWH bridging) per AHA/ASA 2024 (PMID 38483443). ELAN trial (Fischer NEJM 2023 PMID 37162478) supports earlier DOAC initiation (d3–4) for minor/moderate stroke; large infarct (>3 cm or NIHSS ≥16) → 10–14 d delay. CHA2DS2-VASc automatically ≥2 post-stroke → Class I lifelong AC (DOAC preferred unless mechanical valve / severe MS / CrCl <15 → warfarin). Routes acute reperfusion (tPA / TNK / thrombectomy) to neuro.ischaemic-stroke.v1; routes long-term flutter ablation to typical/atypical variants per ECG morphology. Manifest pointer reuses cardio.atrial_flutter.v1 manifest. Design-brief pointer reuses parent. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute.

Entry points (3)

  • symptom
    Acute focal neuro deficit (NIHSS-scored) in patient with known or new atrial flutter — cardioembolic stroke until proven otherwise
    acute_focal_neuro_deficit_with_known_aflutter
  • imaging
    CTA-confirmed LVO + atrial flutter on monitor → emergent thrombectomy + delayed AC
    large_vessel_occlusion_on_cta_with_aflutter_on_telemetry
  • history
    Atrial flutter newly diagnosed on telemetry / extended monitoring during stroke workup — cardioembolic etiology
    new_aflutter_diagnosed_during_stroke_workup

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    CHA2DS2-VASc + thrombolysis age cutoff considerations + frailty/bleed-risk for AC delay decision
  • sbprequired
    vital • used at RED_FLAGS
    BP <185/110 required pre-tPA; permissive HTN in non-tPA candidates; SBP <90 with flutter RVR → DCCV
  • hrrequired
    vital • used at CONTEXT
    Flutter RVR contributes to perfusion mismatch + cardiac demand; HR target 80–110 in stroke + flutter
  • nihssrequired
    symptom • used at INITIAL_WORKUP
    NIHSS drives thrombectomy eligibility (≥6) + AC-delay timing (mild <6 = early AC at d3; severe ≥16 = delay 10–14 d) — AHA/ASA 2024 (PMID 38483443)
  • noncon_ct_head_statrequired
    imaging • used at INITIAL_WORKUP
    STAT non-contrast CT head — rule out hemorrhage; ASPECTS for anterior circulation; required pre-tPA + thrombectomy decision (AHA/ASA 2024)
  • cta_head_neckrequired
    imaging • used at INITIAL_WORKUP
    CTA head/neck for LVO + collateral assessment; drives mechanical thrombectomy decision (DAWN PMID 29129157, DEFUSE-3 PMID 29364767)
  • mri_dwi_for_infarct_extentrequired
    imaging • used at BRANCHING_WORKUP
    MRI/DWI quantifies infarct volume — drives AC-delay window (small 1–3 d, medium 6–7 d, large 10–14 d) per AHA/ASA 2024 + ELAN (PMID 37162478)
  • tte_or_tee_cardiac_sourcerequired
    imaging • used at BRANCHING_WORKUP
    TTE/TEE for cardiac source confirmation — LA appendage thrombus, EF, valve disease; TEE Class I for cryptogenic stroke
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    Confirm flutter morphology + rate; rule out concomitant AF; 30-d ambulatory monitoring if cryptogenic (CRYSTAL-AF)
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    Contrast for CTA + DOAC dose adjustment + tPA exclusion criteria (no specific renal cutoff for tPA)
  • glucoserequired
    lab • used at INITIAL_WORKUP
    Stroke mimic exclusion (hypoglycemia); pre-tPA glucose 50–400 mg/dL
  • platelets_inr_pttrequired
    lab • used at INITIAL_WORKUP
    tPA contraindicated if plt <100k, INR >1.7, PTT abnormal; baseline coags pre-AC restart
  • cha2ds2_vasc_factorsrequired
    history • used at RISK_STRATIFICATION
    CHA2DS2-VASc — score is automatically ≥2 with prior stroke (Class I AC indication post-stroke)
  • bleeding_historyrequired
    history • used at RISK_STRATIFICATION
    HAS-BLED + prior intracranial bleed history may shift toward LAA occlusion (Watchman) instead of long-term AC
  • time_last_known_wellrequired
    history • used at CONTEXT
    tPA within 4.5 h of LKW; thrombectomy within 24 h with perfusion mismatch (DAWN/DEFUSE-3)

12-phase flow (11)

  1. 1FRAME
    Acute ischemic stroke + atrial flutter (new or known) — composite cardioembolic stroke event. Two parallel decisions: (1) acute reperfusion (tPA / TNK / thrombectomy) — same as non-AFL stroke; (2) AC restart timing — withhold 1–14 d per infarct size, NO LMWH bridging — AHA/ASA 2024 (PMID 38483443)
    inputs: nihss, noncon_ct_head_stat, time_last_known_well
    advance: Composite stroke + flutter confirmed
  2. 2ENTRY
    Acute focal neuro deficit + telemetry/ECG with flutter, OR acute stroke workup uncovers flutter — code stroke activated
    inputs: age, time_last_known_well
    advance: Engine entered
  3. 3CONTEXT
    tPA exclusion screen (recent surgery, GI bleed, prior ICH, current AC status); flutter chronicity + prior AC; allergies; comorbidities; baseline mRS
    inputs: hr, cha2ds2_vasc_factors, bleeding_history, time_last_known_well
    advance: Context complete
  4. 4RED_FLAGS
    Hemodynamic instability (SBP <90 with flutter RVR → DCCV); SBP >185/110 in tPA candidate → labetalol/nicardipine; rapidly worsening NIHSS → emergent re-image + thrombectomy/decompressive craniectomy consideration
    inputs: sbp
    actions: tachycardia
    advance: Stable
  5. 5INITIAL_WORKUP
    STAT non-contrast CT head + CTA head/neck + ECG + glucose + coags + CBC + BMP + troponin — full code-stroke panel within door-to-needle 45 min target
    inputs: noncon_ct_head_stat, cta_head_neck, ecg_12_lead, glucose, platelets_inr_ptt, creatinine_egfr
    actions: panel.cardiac, panel.coag, panel.renal
    advance: Stage-1 returned within 45 min
  6. 6BRANCHING_WORKUP
    MRI/DWI for infarct volume → drives AC-delay window; TTE within 24 h for cardiac source; TEE if cryptogenic features; 30-d ambulatory monitor if no flutter on telemetry; route to neuro.ischaemic-stroke.v1 for stroke-specific reperfusion management
    inputs: mri_dwi_for_infarct_extent, tte_or_tee_cardiac_source
    advance: Branch resolved + neuro engine routed
  7. 7RISK_STRATIFICATION
    CHA2DS2-VASc automatically ≥2 (prior stroke = +2); HAS-BLED for AC restart bleed risk; infarct-size-based AC-delay tier (small/medium/large) per AHA/ASA 2024 + ELAN
    inputs: cha2ds2_vasc_factors, bleeding_history
    advance: Tier documented
  8. 8TREATMENT
    Acute reperfusion (tPA 0.9 mg/kg if <4.5 h + no contraindications, OR TNK 0.25 mg/kg per EXTEND-IA TNK; thrombectomy if LVO + DAWN/DEFUSE-3 criteria); AC withhold 1–14 d per infarct size (small <1.5 cm 1–3 d; medium 6–7 d; large >3 cm 10–14 d) — AHA/ASA 2024 (PMID 38483443); ELAN (PMID 37162478) supports early DOAC d3–4 for minor/moderate; NO LMWH bridging; long-term DOAC apixaban/rivaroxaban/dabigatran preferred; flutter rate control with BB/non-DHP CCB
    inputs: nihss, creatinine_egfr
    advance: Reperfusion delivered + AC restart timeline documented
  9. 9DISPOSITION
    Stroke unit / neuro ICU for first 24 h post-tPA or thrombectomy; transfer to comprehensive stroke center if thrombectomy needed; monitor for hemorrhagic conversion + cerebral edema
    advance: Disposition documented
  10. 10MONITORING
    24-h post-tPA NIHSS q15min × 2h then q30min × 6h then q1h; repeat CT at 24 h before AC restart; daily neuro exam; telemetry for flutter; BP target <180/105 post-tPA × 24 h then <140/90
    inputs: ecg_12_lead
    advance: Monitoring orders documented + AC-restart trigger date recorded
  11. 11FOLLOWUP
    Stroke clinic + cardiology + EP for flutter ablation candidacy; ambulatory ECG monitoring if cryptogenic; LDL <70 + statin; BP <130/80; cardiac rehab; long-term DOAC lifelong (CHA2DS2-VASc ≥2)
    advance: Follow-up booked + secondary prevention bundle started