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cardio.atrial_flutter.v1PRODUCTION
cardio.atrial_flutter.v1

Atrial flutter (typical and atypical)

cardiologyacutechronicadult
Hard-required inputs
0 / 13
Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Confirm atrial flutter (sawtooth, atrial rate ~300, conduction ratio); typical (CTI) vs atypical (post-ablation, scar)

Inputs
1
Actions
0
Advance rule
Set
Advance when

Flutter confirmed; type assigned

Patient inputs (15)

CHA2DS2-VASc + ablation candidacy

RVR severity; rate-control target

Recurrence pattern

AAD interactions, AVN-blocker review

Thyrotoxic flutter; reversible cause

K+/Mg correction for AAD safety; renal dosing of DOAC

Anemia worsens RVR symptoms

DOAC dose; AAD dosing

Sawtooth waves; conduction ratio; QTc baseline

Structural disease; LA size; EF; thrombus screen

Hemodynamic instability triggers immediate cardioversion

AC indication; same as AF

HAS-BLED

Tachycardia-mediated cardiomyopathy assessment

Required if cardioverting <48 h without 3-wk therapeutic AC unless TEE-guided

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

Severity triggers (7)

7 need judgement
  • informationallife_threateninghemodynamic_instability_in_flutter
    SBP <90, AMS, ischemia, or pulmonary edema with flutter RVR — ACC/AHA/HRS 2023 (Joglar)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningflutter_with_WPW_pattern
    Pre-excitation + flutter (rapid pre-excited conduction) — ACC/AHA/HRS 2023 (Joglar)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverervr_persistent_despite_AVN_blocker
    HR >120 despite max BB or non-DHP CCB — ACC/AHA/HRS 2023 (Joglar)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepre_cardioversion_no_documented_AC
    Cardioversion planned but no documented therapeutic AC ≥3 wks — ACC/AHA/HRS 2023 (Joglar)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereqtc_prolongation_on_class_III
    QTc >500 or rising 60 ms on dofetilide / sotalol / ibutilide — ACC/AHA/HRS 2023 (Joglar)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterecurrent_typical_flutter
    Recurrent typical (CTI-dependent) flutter despite AAD — ACC/AHA/HRS 2023 (Joglar); HRS 2017
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatethyrotoxic_flutter
    TSH suppressed with elevated T4/T3 in new flutter — ACC/AHA/HRS 2023 (Joglar)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives risk stratification
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Recommended regimen

Atrial flutter — phenotype-stepwise master ladder (typical CTI / atypical / unstable / post-cardiac-surgery / stable RVR) — ACC/AHA 2024 (Joglar PMID 38033089); ESC 2024 (PMID 39210723); Calkins HRS/EHRA/ECAS 2007 (PMID 28506916)
axis: atrial_flutter_phenotype_basedstep 1 - Step 1 — Typical CTI-dependent atrial flutter (most common; curative ablation candidate)
Selected step "Step 1 — Typical CTI-dependent atrial flutter (most common; curative ablation candidate)" — Sawtooth waves with negative deflection in II/III/aVF; counter-clockwise atrial macro-reentry around the cavotricuspid isthmus — ACC/AHA 2024 (Joglar PMID 38033089)
  • metoprolol_tartrate
    first line
    beta_blocker
    5 mg IV q5min × 3 then PO 25–50 mg BID • IV/PO • IV q5min × 3 → PO BID
    triggers: flutter_with_RVR, no_HFrEF_decompensation
    AVN slowing; HR target 80–110 — ACC/AHA 2024 (PMID 38033089)
    rxcui 203191
  • apixaban
    first line
    DOAC_factor_Xa
    5 mg BID (2.5 mg if 2 of: ≥80 yr, ≤60 kg, Cr ≥1.5) • PO • BID
    triggers: CHA2DS2VASc_>=2_men_>=3_women, pre_post_cardioversion, pre_post_ablation
    ARISTOTLE (Granger NEJM 2011 PMID 21870978) — same indication as AF; ACC/AHA 2024 Class I
    rxcui 1364430

outpatient playbook — drug actions (2)

  1. 1. continue rate or rhythm strategy
    per chosen agent • PO • daily / BID
    trigger: Maintenance phase
    Prevent symptoms / recurrence — ACC/AHA/HRS 2023 (Joglar)
  2. 2. continue DOAC or warfarin
    per CHA2DS2-VASc • PO • daily / BID
    trigger: Stroke risk
    Lifelong unless reversed — ACC/AHA/HRS 2023 (Joglar)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Palpitations or fluttering sensation; Dyspnea, fatigue, decreased exercise tolerance; Syncope or pre-syncope.

Objective

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

Assessment

**Atrial flutter (typical and atypical)** (cardio.atrial_flutter.v1).
Phenotype framing: Flutter vs AF vs SVT vs MAT vs sinus tachy with block
Scope: Confirm atrial flutter (sawtooth, atrial rate ~300, conduction ratio); typical (CTI) vs atypical (post-ablation, scar)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Atrial flutter — phenotype-stepwise master ladder (typical CTI / atypical / unstable / post-cardiac-surgery / stable RVR) — ACC/AHA 2024 (Joglar PMID 38033089); ESC 2024 (PMID 39210723); Calkins HRS/EHRA/ECAS 2007 (PMID 28506916)** — step "Step 1 — Typical CTI-dependent atrial flutter (most common; curative ablation candidate)".
1. metoprolol_tartrate 5 mg IV q5min × 3 then PO 25–50 mg BID IV/PO IV q5min × 3 → PO BID (beta_blocker, first line) — AVN slowing; HR target 80–110 — ACC/AHA 2024 (PMID 38033089)
2. apixaban 5 mg BID (2.5 mg if 2 of: ≥80 yr, ≤60 kg, Cr ≥1.5) PO BID (DOAC_factor_Xa, first line) — ARISTOTLE (Granger NEJM 2011 PMID 21870978) — same indication as AF; ACC/AHA 2024 Class I

Setting playbook (outpatient) — Long-term rate or rhythm + AC + ablation referral; lifestyle — ACC/AHA/HRS 2023 (Joglar)
3. continue rate or rhythm strategy per chosen agent PO daily / BID — Maintenance phase (Prevent symptoms / recurrence — ACC/AHA/HRS 2023 (Joglar))
4. continue DOAC or warfarin per CHA2DS2-VASc PO daily / BID — Stroke risk (Lifelong unless reversed — ACC/AHA/HRS 2023 (Joglar))

Non-pharmacologic actions:
- EP for CTI ablation if not done — ACC/AHA/HRS 2023 (Joglar)
- Lifestyle (weight, alcohol, OSA, exercise) — ACC/AHA/HRS 2023 (Joglar)
- Vaccinations — ACC/AHA/HRS 2023 (Joglar)

AVOID / contraindication checks:
- Beta blocker block if decompensated HF — ACC/AHA 2024 (PMID 38033089)
- Non DHP CCB block if EF lt 40 — ACC/AHA 2024 (PMID 38033089)
- Digoxin block if WPW — ACC/AHA 2024 (PMID 38033089)
- Flecainide propafenone block if structural heart disease — CAST (PMID 1900101); ACC/AHA 2024
- Dofetilide REMS inpatient init — ACC/AHA 2024 (PMID 38033089)
- Ibutilide monitor QT 4h — ACC/AHA 2024 (PMID 38033089)
- DOAC renal dose adjustment — ACC/AHA 2024 / ESC 2024

Monitoring

Regimen monitoring:
- telemetry continuous during acute — ACC/AHA 2024 (PMID 38033089)
- HR target 80-110 for rate control — ACC/AHA 2024
- QTc serial with class III AAD or 4h post ibutilide — ACC/AHA 2024
- PFTs TFTs LFT baseline then q6m on amiodarone — ACC/AHA 2024
- CBC eGFR q6m on DOAC — ESC 2024 (PMID 39210723)
- INR per warfarin protocol — ACC/AHA 2024
- 4-week post-CV AC continuation regardless of CHA2DS2VASc — ACC/AHA 2024 Class I (PMID 38033089)

Setting (outpatient) monitoring:
- Cardiology q3-6 mo — ACC/AHA/HRS 2023 (Joglar)
- CBC + eGFR q6m on DOAC — ESC 2024
- Holter if recurrence suspected — ACC/AHA/HRS 2023 (Joglar)

Follow-up plan: EP referral for CTI ablation; cardiology q3–6 mo; chronic AC review; lifestyle (alcohol, weight, OSA)
- Close-out criterion: Follow-up booked

Monitoring phase: Telemetry, AAD QT (esp dofetilide/sotalol/ibutilide), DOAC/INR adherence, K/Mg

Disposition

Current setting: outpatient — Long-term rate or rhythm + AC + ablation referral; lifestyle — ACC/AHA/HRS 2023 (Joglar)

Disposition criteria:
- Continue chronic management — ACC/AHA/HRS 2023 (Joglar)

Escalation triggers (move to higher acuity):
- Recurrent flutter despite ablation → repeat EP — HRS 2017
- New AF after CTI ablation → AF management — ACC/AHA/HRS 2023 (Joglar)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] SBP <90, AMS, ischemia, or pulmonary edema with flutter RVR — ACC/AHA/HRS 2023 (Joglar)
- [LIFE_THREATENING] Pre-excitation + flutter (rapid pre-excited conduction) — ACC/AHA/HRS 2023 (Joglar)
- [SEVERE] HR >120 despite max BB or non-DHP CCB — ACC/AHA/HRS 2023 (Joglar)

Citations

- 2024 ACC/AHA/ACCP/HRS AF + AFL Joint Guideline (Joglar Circulation 2024 PMID 38033089); ESC 2024 AF (Van Gelder EHJ 2024 PMID 39210723); HRS/EHRA/ECAS 2017 catheter ablation expert consensus (Calkins PMID 28506916) [PMID:38033089](https://pubmed.ncbi.nlm.nih.gov/38033089/)
- Cited evidence (PMID 39210723) [PMID:39210723](https://pubmed.ncbi.nlm.nih.gov/39210723/)
- Cited evidence (PMID 28506916) [PMID:28506916](https://pubmed.ncbi.nlm.nih.gov/28506916/)
- Cited evidence (PMID 30874766) [PMID:30874766](https://pubmed.ncbi.nlm.nih.gov/30874766/)
- Cited evidence (PMID 32865375) [PMID:32865375](https://pubmed.ncbi.nlm.nih.gov/32865375/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 2024 ACC/AHA/ACCP/HRS AF + AFL Joint Guideline (Joglar Circulation 2024 PMID 38033089); ESC 2024 AF (Van Gelder EHJ 2024 PMID 39210723); HRS/EHRA/ECAS 2017 catheter ablation expert consensus (Calkins PMID 28506916) — PMID:38033089
  • Cited evidence (PMID 39210723) — PMID:39210723
  • Cited evidence (PMID 28506916) — PMID:28506916
  • Cited evidence (PMID 30874766) — PMID:30874766
  • Cited evidence (PMID 32865375) — PMID:32865375