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cardio.atrial_flutter.typical-cavotricuspid.v1PRODUCTION
cardio.atrial_flutter.typical-cavotricuspid.v1

Typical (CTI-dependent) atrial flutter

cardiologyacutechronicadult
Hard-required inputs
0 / 9
Care setting:

Encounter flow

11/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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

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Typical flutter morphology confirmed

Patient inputs (9)

CHA2DS2-VASc + ablation candidacy

HR ~150 = pathognomonic 2:1 AV conduction in typical flutter; rate target 80–110

Negative sawtooth in II/III/aVF + positive in V1 confirms CTI-dependent counterclockwise circuit (Saoudi 2001 PMID 11428013)

Thyrotoxic flutter — reversible cause; may not need ablation if TFTs normalize

DOAC dosing + contrast for ablation procedure

LA size, EF, valvular disease — ablation safety + LV dysfunction screen

SBP <90 with flutter RVR → emergent DCCV (lower energy than AF, 50–100 J biphasic)

AC indication identical to AF (Class I ACC/AHA 2024)

HAS-BLED + ablation peri-procedure bleed risk

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningunstable_typical_flutter_requires_emergent_dccv
    Typical CTI flutter with SBP <90, AMS, ongoing ischemia, or pulmonary edema → synchronized DCCV 50–100 J biphasic now
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpost_ablation_cardiac_tamponade
    Hypotension + new pericardial effusion within hours of CTI ablation → emergent pericardiocentesis
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpost_ablation_atrioesophageal_fistula
    Fever + chest pain + new neurologic deficit 2–6 weeks post-ablation (rare in CTI but reported) → emergency surgical evaluation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereac_related_bleed_during_4wk_window
    GI bleed, intracranial bleed, or major bleed during mandatory 4-week post-CV AC window
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereav_node_ablation_consideration_for_uncontrolled_RVR
    Persistent uncontrolled RVR despite max AVN blockade + failed CTI ablation + symptomatic — consider AV node ablation + permanent pacemaker
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterecurrent_typical_flutter_on_aad_pre_ablation
    Recurrent typical flutter despite metoprolol + amiodarone → expedite CTI ablation
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives risk stratification
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Recommended regimen

Typical CTI-dependent atrial flutter — rate control + AC + curative CTI ablation pathway — ACC/AHA 2024 (Joglar PMID 38753446); Calkins HRS/EHRA/ECAS 2007 (PMID 17572388)
axis: typical_cti_flutter_curative_pathway
Selected axis "Typical CTI-dependent atrial flutter — rate control + AC + curative CTI ablation pathway — ACC/AHA 2024 (Joglar PMID 38753446); Calkins HRS/EHRA/ECAS 2007 (PMID 17572388)" by default fallback (first axis)
  • metoprolol_tartrate
    first line
    beta_blocker
    5 mg IV q5min × 3 then 25–50 mg PO BID • IV/PO • IV q5min × 3 → PO BID
    triggers: typical_flutter_with_RVR, no_HFrEF_decompensation
    AVN slowing for 2:1 conducted typical flutter; HR target 80–110 — ACC/AHA 2024 (PMID 38753446)
    rxcui 203191
  • metoprolol_succinate
    first line
    beta_blocker
    25–50 mg PO daily • PO • once daily
    triggers: chronic_rate_control_pre_ablation
    Long-acting BB bridge to CTI ablation — ACC/AHA 2024
    rxcui 866427
  • diltiazem
    first line
    non_DHP_CCB
    0.25 mg/kg IV bolus → 5–15 mg/h infusion; 120–360 mg PO daily • IV/PO • IV bolus + infusion → PO daily
    triggers: BB_intolerant, EF_preserved, COPD_with_bronchospasm
    AVN slowing alternative; AVOID in HFrEF EF<40 — ACC/AHA 2024 (PMID 38753446)
    rxcui 3443
  • ibutilide
    first line
    class_III_AAD
    1 mg IV over 10 min (0.01 mg/kg if <60 kg); may repeat ×1 • IV • single dose, may repeat once
    triggers: stable_typical_flutter_chemical_CV, baseline_QTc_<440
    Ibutilide ~60% conversion rate for typical flutter (vs ~30% for AF); monitor QT 4 h post-dose for torsades (~3% risk) — ACC/AHA 2024 (PMID 38753446)
    rxcui 41289
  • apixaban
    first line
    DOAC_factor_Xa
    5 mg BID (2.5 mg BID if 2 of: ≥80 yr, ≤60 kg, Cr ≥1.5) • PO • BID
    triggers: CHA2DS2VASc_>=2_men_>=3_women, pre_post_cardioversion, pre_post_CTI_ablation
    AC same as AF; mandatory 4-week post-CV AC regardless of score — ACC/AHA 2024 Class I (PMID 38753446); ARISTOTLE (PMID 21870978)
    rxcui 1364430
  • rivaroxaban
    first line
    DOAC_factor_Xa
    20 mg with food (15 mg if CrCl 15–50) • PO • once daily
    triggers: CHA2DS2VASc_>=2, apixaban_unavailable
    X-VeRT (PMID 24837375) — peri-CV efficacy = warfarin; ROCKET-AF foundational
    rxcui 1114195

outpatient playbook — drug actions (2)

  1. 1. continue DOAC if CHA2DS2-VASc ≥2
    rxcui 1364430
    apixaban 5 mg BID per CHA2DS2-VASc • PO • BID
    trigger: Persistent stroke risk
    Lifelong AC — ACC/AHA 2024 Class I
  2. 2. discontinue rate-control AAD post-successful ablation
    rxcui 866427
    Wean metoprolol over 4–8 weeks if no recurrence • PO • taper
    trigger: Successful CTI ablation + no recurrence at 3 mo
    No further AAD needed if CTI ablation successful — ACC/AHA 2024

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Sawtooth flutter waves negative in II/III/aVF (counterclockwise CTI-dependent reentry); Palpitations with regular narrow-complex tachy at HR ~150 (2:1 AV conduction signature); Recurrent typical flutter after prior cardioversion → CTI ablation candidate.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Typical (CTI-dependent) atrial flutter** (cardio.atrial_flutter.typical-cavotricuspid.v1).
Scope: 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

No severity triggers fired against current inputs.

Plan

Regimen axis: **Typical CTI-dependent atrial flutter — rate control + AC + curative CTI ablation pathway — ACC/AHA 2024 (Joglar PMID 38753446); Calkins HRS/EHRA/ECAS 2007 (PMID 17572388)**.
1. metoprolol_tartrate 5 mg IV q5min × 3 then 25–50 mg PO BID IV/PO IV q5min × 3 → PO BID (beta_blocker, first line) — AVN slowing for 2:1 conducted typical flutter; HR target 80–110 — ACC/AHA 2024 (PMID 38753446)
2. metoprolol_succinate 25–50 mg PO daily PO once daily (beta_blocker, first line) — Long-acting BB bridge to CTI ablation — ACC/AHA 2024
3. diltiazem 0.25 mg/kg IV bolus → 5–15 mg/h infusion; 120–360 mg PO daily IV/PO IV bolus + infusion → PO daily (non_DHP_CCB, first line) — AVN slowing alternative; AVOID in HFrEF EF<40 — ACC/AHA 2024 (PMID 38753446)
4. ibutilide 1 mg IV over 10 min (0.01 mg/kg if <60 kg); may repeat ×1 IV single dose, may repeat once (class_III_AAD, first line) — Ibutilide ~60% conversion rate for typical flutter (vs ~30% for AF); monitor QT 4 h post-dose for torsades (~3% risk) — ACC/AHA 2024 (PMID 38753446)
5. apixaban 5 mg BID (2.5 mg BID if 2 of: ≥80 yr, ≤60 kg, Cr ≥1.5) PO BID (DOAC_factor_Xa, first line) — AC same as AF; mandatory 4-week post-CV AC regardless of score — ACC/AHA 2024 Class I (PMID 38753446); ARISTOTLE (PMID 21870978)
6. rivaroxaban 20 mg with food (15 mg if CrCl 15–50) PO once daily (DOAC_factor_Xa, first line) — X-VeRT (PMID 24837375) — peri-CV efficacy = warfarin; ROCKET-AF foundational

Setting playbook (outpatient) — Long-term post-CTI ablation surveillance, AC management based on CHA2DS2-VASc and ablation success, lifestyle modification, screening for incident AF (~25% post-CTI ablation) — ACC/AHA 2024 (PMID 38753446)
7. continue DOAC if CHA2DS2-VASc ≥2 apixaban 5 mg BID per CHA2DS2-VASc PO BID — Persistent stroke risk (Lifelong AC — ACC/AHA 2024 Class I)
8. discontinue rate-control AAD post-successful ablation Wean metoprolol over 4–8 weeks if no recurrence PO taper — Successful CTI ablation + no recurrence at 3 mo (No further AAD needed if CTI ablation successful — ACC/AHA 2024)

Non-pharmacologic actions:
- Lifestyle: weight, alcohol limit, OSA treatment, exercise (ACC/AHA 2024)
- Vaccinations + secondary prevention bundle (ACC/AHA 2024)

AVOID / contraindication checks:
- Beta blocker block if decompensated HF — ACC/AHA 2024 (PMID 38753446)
- Non DHP CCB block if EF lt 40 — ACC/AHA 2024 (PMID 38753446)
- Ibutilide monitor QT 4h_post_dose — ACC/AHA 2024 (PMID 38753446)
- Flutter CV requires AC 3wks or TEE — ACC/AHA 2024 (PMID 38753446)
- DOAC renal dose adjustment — ESC 2024 (PMID 39050851)

Monitoring

Regimen monitoring:
- telemetry continuous acute — ACC/AHA 2024
- HR target 80-110 pre ablation — ACC/AHA 2024
- QTc 4h post ibutilide — ACC/AHA 2024
- 4-week post-CV AC continuation regardless of CHA2DS2VASc — ACC/AHA 2024 Class I
- post-ablation groin check first 4h then q4h ×24h — HRS 2007 (PMID 17572388)
- post-ablation 4-week ECG + Holter 3mo for recurrence — Calkins 2007

Setting (outpatient) monitoring:
- Cardiology q3–6 mo first year, then annually (ACC/AHA 2024)
- Holter at 3, 6, 12 mo post-ablation (Calkins 2007)
- CBC + eGFR q6m on DOAC (ESC 2024)

Follow-up plan: 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
- Close-out criterion: Follow-up booked + ablation pathway entered

Monitoring phase: Telemetry post-CV; QTc post-ibutilide × 4 h; post-ablation observation for groin hematoma + tamponade; AC adherence

Disposition

Current setting: outpatient — Long-term post-CTI ablation surveillance, AC management based on CHA2DS2-VASc and ablation success, lifestyle modification, screening for incident AF (~25% post-CTI ablation) — ACC/AHA 2024 (PMID 38753446)

Disposition criteria:
- Continue chronic surveillance; this engine continues unless transitions to AF predominant

Escalation triggers (move to higher acuity):
- Recurrent typical flutter despite ablation → repeat EP mapping — HRS 2007
- New AF after successful CTI ablation (~25%) → AF management via cardio.afib.core.v1
- Stroke / TIA on AC → workup + consider switch — ACC/AHA 2024

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Typical CTI flutter with SBP <90, AMS, ongoing ischemia, or pulmonary edema → synchronized DCCV 50–100 J biphasic now
- [LIFE_THREATENING] Hypotension + new pericardial effusion within hours of CTI ablation → emergent pericardiocentesis
- [LIFE_THREATENING] Fever + chest pain + new neurologic deficit 2–6 weeks post-ablation (rare in CTI but reported) → emergency surgical evaluation

Citations

- 2024 ACC/AHA/ACCP/HRS AF + AFL Joint Guideline (Joglar Circulation 2024 PMID 38753446); ESC 2024 AF (Van Gelder EHJ 2024 PMID 39050851); HRS/EHRA/ECAS 2007 catheter ablation expert consensus (Calkins PMID 17572388) [PMID:38753446](https://pubmed.ncbi.nlm.nih.gov/38753446/)
- Cited evidence (PMID 39050851) [PMID:39050851](https://pubmed.ncbi.nlm.nih.gov/39050851/)
- Cited evidence (PMID 17572388) [PMID:17572388](https://pubmed.ncbi.nlm.nih.gov/17572388/)
- Cited evidence (PMID 11428013) [PMID:11428013](https://pubmed.ncbi.nlm.nih.gov/11428013/)
- Cited evidence (PMID 30874727) [PMID:30874727](https://pubmed.ncbi.nlm.nih.gov/30874727/)

Last reconciled with current guidelines: 2026-05-14.
References
  • 2024 ACC/AHA/ACCP/HRS AF + AFL Joint Guideline (Joglar Circulation 2024 PMID 38753446); ESC 2024 AF (Van Gelder EHJ 2024 PMID 39050851); HRS/EHRA/ECAS 2007 catheter ablation expert consensus (Calkins PMID 17572388) — PMID:38753446
  • Cited evidence (PMID 39050851) — PMID:39050851
  • Cited evidence (PMID 17572388) — PMID:17572388
  • Cited evidence (PMID 11428013) — PMID:11428013
  • Cited evidence (PMID 30874727) — PMID:30874727