How does atrial fibrillation differ from atrial fibrillation? Atrial flutter: causes, when to seek help, treatment methods

The rhythmicity of contractions and pulse is the little thing that distinguishes atrial flutter (fibrillation), the symptoms of which are oriented towards a similar picture occurring in other cases of atrial fibrillation, with an equally significant number of contractions. Clinical manifestations are differentiated by certain indications and a more rhythmic pulse.

General principles of treatment are characteristic of both pathologies, and sometimes the process smoothly flows from one to the other. Atrial fibrillation and atrial flutter are often indicated in a similar pathology, or provide grounds for making a valid diagnosis indicating both conditions. Sometimes, instead of atrial flutter, the term is used: a type of atrial fibrillation.

What is pathology

Atrial fibrillation and flutter are supraventricular tachycardia and cardiac arrhythmias, leading to paroxysmal tachycardia. Cardiac pathologies, which are sometimes classified as subtypes of atrial fibrillation.

Usually called atrial flutter (AF), it is common in men over 60 years of age who already suffer from some type of cardiac pathology, but is difficult to reliably establish in diagnosis and ECG, due to its instability. Severe structural changes in the ventricles, and sometimes lead to the question of cardiac surgery as the disorder progresses.

Characteristics of pathology and probable signs

A large group of tachyarrhythmias, which include atrial flutter, is pathological disorders cardiac activity, with a characteristic increase in contraction frequency. Source of origin pathological process, located in the atrium, leads to an increase in heart rate several times.

At a normal rate of 60-90 beats per minute, the frequency of contractions during flutter can be 200-300. Maintaining the correct oscillation rhythm is one of the main characteristics that are used in determining a type of atrial fibrillation called atrial fibrillation.

Paroxysm of atrial flutter is the time during which it occurs, with a variable duration from a second to lasting several days. Under the influence of treatment, TP quite quickly turns into atrial fibrillation, or sinus rhythm, which was the reason for the lack of a stable determination of the duration of paroxysms.

The constant form of flutter is an extremely rarely diagnosed pathology, since flutter often replaces each other. There are two types of attacks:

• Type 1 (atrial flutter 1) is relieved by electrical stimulation and is characterized by a frequency of 240 to 339 per minute, with F waves displayed in the form of a sawtooth uniform shape;
• Type 2 cannot be interrupted by stimulation, the F-F wave intervals are uneven, the frequency per minute can reach from 340 to 430.

The classification of atrial flutter distinguishes:

• paroxysmal and constant;
• according to types 1 and 2;
• atypical and typical (classical) development of events.

In classical excitation waves, they arise in the right atrium and occur with a flutter frequency of 240 to 340 vibrations per minute. With atypical, circulation can occur in both the left and right atrium, but is accompanied by waves with an oscillation frequency of 340 to 440 vibrations per minute, following an atypical pattern. Based on the place of formation they distinguish:

• right atrial (upper loop and multiple cycle);
• left atrial isthmus-independent flutter.

Classification of pathology according to clinical course

Another division, according to clinical course, implies:

• first developed;
• paroxysmal;
• persistent;
• permanent.

Paroxysmal form lasts less than 7 days, persistent - more than a week, permanent is said to be when the therapy was not carried out, or was carried out, but did not bring the desired and expected result. An attack can occur once a year or several times a day.

The frequency of occurrence of such cardiac disorders depends on the age, gender and etiological characteristics of each patient. Most often, they affect older men who already have a history of heart pathologies.

Diagnosis of disorders

The only thing that can be determined in this condition by visual inspection is the presence of a rapid pulse, which maintains relative external constancy. When the coefficient is measured frequently, it is discovered that the pulse loses its rhythm.

Clinical symptoms are characteristic of almost any cardiac pathology accompanied by rhythm disturbances. Only the pulsation of the jugular veins, the frequency of which is twice as high as the arterial pulse, but coincides with the rhythm of the atria, gives grounds for a presumptive diagnosis.

An ECG allows you to establish:

• absence of P-waves;
• the presence of unchanged ventricular complexes;
• high frequency;
• sawtooth F-waves.

But the rhythm of ventricular contraction remains correct. To clarify the preliminary diagnosis, a complex diagnostic measures:

• monitoring of ECG conditions;
• transesophageal echocardiography;
• blood chemistry;
• Ultrasound of the heart;
• electrophysiological study.

If you analyze all the collected diagnostic data, you can establish not only the nature of the pathology, but also its etiological reasons. One of the most common causes is concomitant cardiac dysfunction, which, as a rule, is not always the only one, and requires certain nuances in the treatment of atrial flutter.

Associated symptoms of pathology

Symptoms cardiological pathology are of a general, unexpressed nature, typical of many cardiac disorders. Without expressed clinical picture similar symptoms are taken as signs concomitant disease which has already been diagnosed and observed:

• dyspnea;
• fast fatiguability;
• apathy;
• depressed state;
• decreased physical activity;
• experienced oxygen deficiency during physical effort.

Such symptoms are characteristic of many diseases. Angina pectoris is not taken into account as symptoms, but is considered as a specific pathology, most characteristic of overweight, or static position in nature professional activity, age, general physical condition.

Syncope, pronounced arrhythmia, similar to atrial fibrillation, painful sensations in the chest, can also be correlated with existing heart disease. And only diagnosis with a pronounced negative clinical condition, or a routine examination, makes it possible to correlate the perceived arrhythmia with atrial flutter, which can be replaced by it.

Causes of fluttering

Risk factors that appear when collecting a patient’s medical history also do not allow us to trace the presence of clearly manifested patterns.

Only one of them can be identified as common - stressful situations that lead to emotional disturbance, nervous overstrain, destabilization of the psycho-emotional state.

Other reasons include:

• increased thrombus formation and high blood clotting;
• atherosclerosis, with increased hardening of blood vessels;
• functional defects of the cardiovascular system acquired in fetal development;
• pulmonary pathologies (emphysema or embolism);
• diseases of the endocrinological system ( thyroid gland);
• pathological decrease or enlargement of the chambers of the heart;
• chronic diseases of internal organs;
• pathology of the body's metabolic system.

A separate group includes iatrogenic causes (surgeries and surgical interventions). Any of the above reasons may appear as individual disease, which is accompanied by a violation of cardiac activity, as a result of an unhealthy lifestyle.

Use junk food, disruption of the normal rhythm of sleep, lack of periodicity in eating, frequent drinking, smoking - all this can lead to the development of cardiac pathology, and atrial flutter, as its direct consequence.

Drug treatment

The nature of the course of disorders of the heart, with atrial flutter and fibrillation, is similar in the mechanisms of development and biochemical changes, which implies similar areas of treatment and normalization of the heart rhythm. Both medicinal and non-medicinal medicinal methods cardioversions. Specialized observations show that drugs are less effective for flutter than for fibrillation.

Relief of flutter is more effective when using, or electropulse therapy. When it is fundamentally impossible, due to objective reasons, to use these two methods, they are replaced by intravenous infusion of ibutilide. Amiodarone, Sotalol, and other antiarrhythmics show less efficacy than ibutilide (from 38 to 76%) when administered.

To quantitatively reduce the vibrations produced and slow down the rapid heartbeat, the following are used:

• beta blockers, Digoxin, Adenosine;
• Calcium channels are blocked by Diltiazem and Verapamil.

Antiarrhythmics are prescribed according to individual indications, the predominant option is Ibutilide, but the following are also used:

• Sotalol;
• Propafenone;
• Flecainide;
• Amiodarone;
• Dofetilide.

Blood thinners are used for irregular fluttering. Traditional and folk medicine recognizes the effectiveness of homeopathic digitalis preparations in all cases except severe hemodynamic lesions. Digitalis is not very effective for long-term and chronic forms.

In these cases, it is not possible to restore sinus rhythm with the help of a herbal preparation. Novocainamide is also noted, which is also used for fibrillation.

Selection of drugs for drug therapy takes into account the general condition of the patient, the frequency of atrial fibrillation, and the condition circulatory system. Most often, Anaprilin, Bisopropol and Metapropol are prescribed, despite the fact that the number of antiarrhythmics produced by the pharmaceutical industry is quite large. Regular use of such drugs is aimed at normalizing sinus rhythm and preventing possible violations cardiac activity.

Lifestyle with cardiac pathology

An important method of preventing the occurrence of pathology is diet and the concomitant elimination of any irritating factors. Tea, coffee, sweet carbonated drinks and any alcohol-containing drinks should be excluded from consumption.

The diet is based on fluid restriction, and partial and fractional processes of eating. Products that can cause bloating and flatulence are strictly prohibited. The amount of salt consumed is also limited. The diet is practically salt-free.

The appearance of cardiac arrhythmias requires self-discipline from the patient, regular use of prescribed medications, and caution with any factors that can provoke the progression of the pathology and the appearance of new attacks.

Atrial flutter that is caused by non-cardiac conditions usually resolves by treating the underlying cause of the cardiac disorder. However, a visit to a cardiologist is inevitable if a person wants to maintain a healthy heart.

Atrial fibrillation (AF) is a chaotic, uncoordinated contraction of the atrial myocardium with a frequency of over 400 per minute. At this frequency, there is virtually no full-fledged contraction of the atria - they simply fibrillate, flicker, and their mechanical function for active expulsion of blood is zero. For clarity, I will briefly mention some features of cardiac anatomy and physiology. Normally, electrical stimulation in the heart is generated in a specialized location in the right atrium called the sinus node. From it, excitation spreads along the conduction system to the atrial myocardium (electromechanical coupling occurs and the atria contract), then to the atrioventricular (AV) connection and, finally, to the ventricles (electromechanical coupling occurs and the ventricles contract). At the AV junction, the electrical impulse is “delayed” for a fraction of a second, due to which the atria contract first, then the ventricles (Fig. 1).

Fig.1

Let me remind you that blood flows to the heart through two large vena cava, which flow into the right atrium. From the right atrium, blood flows into the right ventricle, then into the pulmonary artery; branches pulmonary artery branch to the lung parenchyma - the blood is enriched with oxygen and freed from carbon dioxide. Oxygenated blood from the lungs through the pulmonary veins enters the left atrium, then into the left ventricle, from which it is released into the aorta and its branches - the blood flows to all organs and tissues (Fig. 2, 3).

Fig.2 Fig.3

With atrial fibrillation, there is no effective contraction (systole) of the atria and blood flows from them to the ventricles simply according to the principle of difference in pressure gradients. On the ECG, atrial contraction is represented by the P wave, and ventricular contraction is represented by the QRS complex. At sinus rhythm each atrial P wave is followed by a ventricular QRS complex (Fig. 4).

Fig.4

In atrial fibrillation, there are no P waves in front of the ventricular complexes, since the atria do not contract (Fig. 5).

Fig.5

I mentioned above that from the atria to the ventricles the electrical impulse travels through the so-called AV junction, in which the impulse is delayed for a fraction of a second. In atrial fibrillation, the AV connection is “attacked” by a huge number of chronologically unstructured impulses, and therefore, electrical impulses arrive frequently and asynchronously to the ventricles. Therefore, the ventricles contract irregularly and, as a rule, frequently (Fig. 5).

R reflex contractions of the esophagus that occur against the background peptic ulcer stomach, reflux esophagitis, cholecystitis

These are the 4 most common reasons!

R weakening of the diaphragm due to traumatic or inflammatory damage to the phrenic nerve (rare cause)

Innate Prerequisites(congenital hiatal hernia in children; f formation of a congenital hernial sac due to untimely fusion of the diaphragm; nunderdevelopment of the diaphragm in the area covering hiatus, due to which it appears expanded) , facilitating the occurrence of a hernia, including for the reasons mentioned above

The prevalence of hiatal hernia is high: among people over 60 years of age, it is diagnosed in every third person! The hiatal hernia can be sliding, when the protrusion occurs situationally under the influence of provoking factors and is permanent. Compression (irritation) of the vagus during a sliding or constant hiatal hernia leads to the occurrence of reflexes on the heart, which results in cardiac arrhythmias. The vagus innervates only the structures of the atria, therefore vagal arrhythmias are exclusively atrial ( atrial extrasystole, atrial tachycardia, atrial fibrillation). HH is a gastroenterological disease, however, approximately 1/3 of patients with this pathology have no gastroenterological symptoms (pain in the epigastric region, burning behind the sternum, heartburn, belching) at all, but only reflex arrhythmias are present: symptomatic or asymptomatic.

Sometimes the displacement of the stomach does not reach the level of “herniation,” but even this is enough to trigger vagal reflexes.

Thus, the main phenomenon of vagus-dependent atrial fibrillation is its primary cause in an organ that has common innervation with the heart. In the vast majority of cases, this “organ” turns out to be the place of anatomical contact of the esophagus, stomach and diaphragm.

When we talk about the excessive effect of the vagus on the heart, we mean that it creates zones of slow, heterogeneous electrical conduction in the atria, that is, it forms a substrate for arrhythmia. First, extrasystole appears (everything can be limited to it only for years), subsequently, if the vagus continues to be irritated, runs of atrial tachycardia occur; finally, when the atria are exposed to vagal influences for a long time, it becomes possible to maintain fibrillation in the atria.

The hiatal hernia is reliably diagnosed by fluoroscopy of the esophagus; however, if the hernia is sliding, then it will be visible only with simultaneous provocative tests that increase intra-abdominal pressure. Indirect signs of hiatal hernia can sometimes be detected using conventional FGDS. Sometimes a minimal and short-term “sliding” of the hernia is enough (for example, at the moment of a sharp turn of the body) for atrial fibrillation to “suddenly” start.

IN agus-dependent AF occurs not only due to the hiatal hernia - this is the leading cause, but there are others: cardia failure, reflux esophagitis (including endoscopically negative), cholecystocardial syndrome (gallbladder diseases - dyskinesia, stones, inflammation - can provoke reflex vagal extrasystole). Sometimes the causes of excessive vagal impulses cannot be determined. As a rule, in such cases, age-related involution of the ligamentous apparatus of the esophagus occurs, when even absolutely habitual body movements (getting out of bed, bending over, moving to a horizontal position) provoke some displacement of the esophagus and, as a result, irritation of the vagus.

If any other types of AF are more or less satisfactorily treated with cardiotropic drugs, then in the treatment of vagal AF gastroenterological treatment (drug and non-drug) aimed at reducing vagal reflexes and lifestyle modification is paramount. The main “philosophical” message of vagus-dependent AF: you and your heart are detrained!

After successful RFA surgery, there is an increased risk of recurrence of atrial fibrillation within 2-3 months. However, paroxysms of arrhythmia that occur during this time interval do not reflect the absolute ineffectiveness of the operation. The likelihood of atrial fibrillation is high due to the fact that it takes time for the formation of full-fledged scar tissue at the site of ablation effects; in addition, early relapses are explained by the gradually developing phenomenon of reverse remodeling of the atrial myocardium. Often, after 2-3 months, paroxysms of atrial fibrillation spontaneously stop, that is, a delayed “cure” takes place. In this regard, a special term “blind period” was introduced - the time during which the effectiveness of the operation is not assessed. Paroxysms that occur during this period are not an indication for immediate re-ablation, but can be treated with medication or electrical cardioversion. Relapses of atrial fibrillation occurring after the end of the “blind period” (according to different authors it lasts up to 2-4 months), reflect the ineffectiveness of the RFA operation.

Atrial fibrillation is distinguished by types, which depend on several criteria: the duration of the episode, the frequency of contractions of the ventricles of the heart muscle, the nature of the individual waves. The presence of appropriate classifications is of particular value in terms of diagnosing cardiac dysfunction.

Classification by episode duration

Depending on the duration, the following types of atrial fibrillation are distinguished:

• First identified. This form is diagnosed if manifestations of the deviation are detected for the first time, regardless of the severity or presence of the clinical picture. The attack lasts 10-15 minutes.
• Paroxysmal. Violation of the heart rhythm is recurrent and stops spontaneously. Usually the attack lasts two days or less. This type of atrial fibrillation is not characterized by the duration of episodes and does not exceed seven days. Most often, the phenomenon is observed for 1-2 days, but its minimum duration is 3 minutes. With this form, as with the previous one, there is a possibility of spontaneous restoration of the heart rhythm.
• Persistent. This type fibrillation differs in duration: an attack can last more than 7 days in a row. With long-term persistent forms, the symptoms of deviations are observed for more than twelve months.
• Constant. This form has existed for a long time. The clinical picture of persistent AF is determined by periods of recurrent attacks. The permanent type of atrial fibrillation is special: in this case, it is not possible to restore the rhythm. Measures are being taken to monitor heart rate indicators.

Classification according to the criterion of ventricular contraction frequency

Based on the factor of ventricular contraction frequency, the following forms of pathology are distinguished:

• Tachysystolic. In this case, more impulses than necessary are delivered to the ventricles, causing the pulse rate to be more than 100 beats per minute.
• Bradysystolic. With this form, the heart rate is within normal limits or reduced (less than 60 beats per minute), but the pulse remains normal.
• Normosystolic. In this form, the ventricles contract with a frequency that is as close as possible to normal values ​​(from 60 to 100 beats per minute).

When character changes physical activity, and also depending on the degree emotional stress, various variants of pathology, classified by the frequency of contraction of the ventricles of the heart, can replace each other.

Classification by the nature of waves F

F waves on an electrocardiogram represent the total action potential of the heart muscle that occurs during electrical stimulation.

Depending on this criterion, the following types of fibrillation are distinguished:

• Large wave. In this case, the ECG shows large and sparse waves of atrial fibrillation. This form of AF is usually observed with defects of the heart muscle, which causes overload of the atria.
• Fine fiber. The ECG shows frequent and small waves of atrial fibrillation, which is usually characteristic of cardiosclerosis.

Classification by severity of symptoms (EHRA scale)

The Symptom Rating Scale (EHRA) is a clinical tool that assesses symptoms during episodes of atrial fibrillation. It helps determine the course of treatment for a patient suffering from arrhythmia.

Depending on this criterion, the following types of AF are distinguished:

• EHRA I – this value indicates the absence of symptoms;
• EHRA II - in this case, the severity of the symptoms of the deviation is mild, due to which the patient’s daily activity is not disrupted;
• EHRA III – the clinical picture is severe, the symptoms are so severe that the patient’s daily activity is impaired;
• EHRA IV is the most severe indicator, as it indicates the presence of symptoms that lead to disability of the patient, which not only limits, but completely stops the patient’s daily activity.

The diagnosis of forms of atrial fibrillation is made based on the results obtained during an ECG. Often, long-term ECG observation is required to confirm the diagnosis, which can last from 1 to 7 days.

The difference between fibrillation and atrial flutter

Many people equate these concepts, but in reality they are two different states, which are typical for. The difference between them lies in the mechanism of action:

• with flutter, the myocardial fibers contract slowly;
• during fibrillation, the impulses that are supplied to the myocardium are chaotic in nature and contribute to the fact that its fibers begin to contract too quickly and unevenly.

Atrial fibrillation and flutter are manifestations of atrial fibrillation, which poses a particular danger to the patient’s health. In particular, this pathology can cause thrombosis and pulmonary embolism, and the development of stroke.

These conditions arise under the influence of factors such as:

• heart valve defects;
• congenital or acquired pathologies of the heart muscle;
• cardiac ischemia.

Atrial fibrillation, which is expressed in atrial fibrillation or flutter, is also caused by pathologies not associated with dysfunction of the heart muscle. So, this condition can be triggered by adrenal tumors, hyperfunction of the thyroid gland, obesity and diabetes mellitus.

Another factor that can cause atrial fibrillation and flutter is alcohol abuse.

Classification of atrial flutter

Atrial flutter is a phenomenon that, like fibrillation, can manifest itself in different forms.

The main classification is the following division of pathology:

• Typical atrial flutter, or type 1. In this case, the following changes are observed: the pathological wave of excitation is directed counterclockwise, up the interatrial septum. After that she goes to back wall right atrium. Next, the impulse bypasses the mouth of the superior vena cava, reaches its original position, after which the cycle resumes.
• Atypical atrial flutter of the second type. In this case, the passage of the pathological impulse excludes the isthmus.

WITH clinical point There are two main types of atrial flutter:

• . An attack of arrhythmia occurs suddenly, usually under the influence of provoking factors, and does not last long.
• Permanent form. In this case, heart rhythm disturbances are observed on an ongoing basis.

The existing classifications of atrial fibrillation and flutter facilitate the diagnosis and development of a course of management of a patient with atrial fibrillation. The classifications are based on various factors related to the nature of the manifestation of pathology.

Yu. A. Bunin
Doctor medical sciences, professor, RMAPO, Moscow

Atrial fibrillation (AF) is one of the most common tachyarrhythmias in clinical practice, its prevalence in the general population ranges from 0.3 to 0.4%. The detection of AF increases with age. So, among people under 60 years old, it is approximately 1% of cases, and in the age group over 80 years old - more than 6%. About 50% of patients with atrial fibrillation in the United States are over 70 years of age, and more than 30% of those hospitalized due to cardiac arrhythmias are patients with this arrhythmia. Atrial flutter (AF) is a significantly less common arrhythmia compared to AF. In most countries, FI and TP are considered as various disorders rhythm and are not combined under the general term “atrial fibrillation”. In our opinion, this approach should be considered correct for many reasons.

Prevention of thromboembolic complications and recurrence of atrial fibrillation and flutter

Atrial fibrillation and flutter worsen hemodynamics, aggravate the course of the underlying disease and lead to an increase in mortality by 1.5-2 times in patients with organic heart disease. Non-valvular (non-rheumatic) AF increases the risk of ischemic stroke by 2-7 times compared with the control group (patients without AF), and rheumatic mitral valve disease and chronic AF - by 15-17 times. The frequency of ischemic stroke in non-rheumatic atrial fibrillation averages about 5% of cases per year and increases with age. Cerebral emboli recur in 30-70% of patients. The risk of another stroke is highest during the first year. Low risk stroke in patients with idiopathic AF younger than 60 years (1% per year), slightly higher (2% per year) - at the age of 60-70 years. In this regard, most patients with frequent and/or prolonged paroxysms of atrial fibrillation, as well as its permanent form, should be prevented from thromboembolic complications. A meta-analysis of all studies on primary and secondary prevention of strokes showed that indirect anticoagulants reduce the risk of developing the latter by 47-79% (on average by 61%), and aspirin by a little more than 20%. It should be noted that when using aspirin, a statistically significant reduction in the incidence of ischemic stroke and other systemic embolisms is possible only with a fairly high dose of the drug (325 mg/day). At the same time, in the Copenhagen AFASAK Study, the number of thromboembolic complications in the groups of patients receiving aspirin 75 mg/day and placebo did not differ significantly.

In this regard, patients with AF who are at high risk for thromboembolic complications: heart failure, EF 35% or less, arterial hypertension, ischemic stroke or transient ischemic attack history, etc., - indirect anticoagulants should be prescribed (maintaining the International Normalized Ratio - INR - at an average level of 2.0-3.0). For patients with non-valvular (non-rheumatic) atrial fibrillation who are not at high risk, continuous use of aspirin (325 mg/day) is advisable. There is an opinion that in patients under 60 years of age with idiopathic AF, in whom the risk of thromboembolic complications is very low (almost the same as in people without rhythm disturbances), preventive therapy may not be required. Antithrombotic therapy in patients with AFL should obviously be based on taking into account the same risk factors as in AF, since there is evidence that the risk of thromboembolic complications in AFL is higher than in sinus rhythm, but slightly lower than in AF.

International experts offer the following specific recommendations for antithrombotic therapy various groups patients with atrial fibrillation depending on the level of risk of thromboembolic complications:

age less than 60 years (no heart disease - lone AF) - aspirin 325 mg/day or no treatment; age less than 60 years (heart disease, but no risk factors such as congestive heart failure, EF 35% or less, arterial hypertension) - aspirin 325 mg/day; age 60 years or more (diabetes mellitus or coronary artery disease) - oral anticoagulants (INR 2.0-3.0); age 75 years or more (especially women) - oral anticoagulants (INR up to 2.0); heart failure - oral anticoagulants (INR 2.0-3.0); LVEF 35% or less - oral anticoagulants (INR 2.0-3.0); thyrotoxicosis - oral anticoagulants (INR 2.0-3.0); arterial hypertension - oral anticoagulants (INR 2.0-3.0); rheumatic heart defects (mitral stenosis) - oral anticoagulants (INR 2.5-3.5 or more); artificial valves hearts - oral anticoagulants (INR 2.5-3.5 or more); history of thromboembolism - oral anticoagulants (INR 2.5-3.5 or more); the presence of a thrombus in the atrium, according to TPEchoCG, - oral anticoagulants (INR 2.5-3.5 or more).

The international normalized ratio should be monitored with indirect anticoagulants at the beginning of therapy at least once a week, and subsequently monthly.

In most cases, patients with recurrent paroxysmal and persistent atrial fibrillation in the absence of clinical symptoms of arrhythmia or their insignificant severity do not need to be prescribed antiarrhythmic drugs. In such patients, prophylaxis of thromboembolic complications (aspirin or indirect anticoagulants) and heart rate control are carried out. If clinical symptoms are pronounced, anti-relapse and relief therapy is required, combined with heart rate control and antithrombotic treatment.

In case of frequent attacks of atrial fibrillation and flutter, the effectiveness of antiarrhythmics or their combinations is assessed clinically; in case of rare attacks, TEES or VEM is performed for this purpose after 3-5 days of taking the drug, and when using amiodarone - after saturation with it. To prevent relapses of AF/AFL in patients without organic heart disease, antiarrhythmic drugs of classes 1A, 1C and 3 are used. In patients with asymptomatic LV dysfunction or symptomatic heart failure, and possibly with significant myocardial hypertrophy, therapy with class 1 antiarrhythmics is contraindicated due to the risk of worsening life prognosis.

To prevent paroxysms of atrial fibrillation and atrial flutter, the following antiarrhythmics are used: quinidine (kinylentine, quinidine durules, etc.) - 750-1500 mg/day; disopyramide - 400-800 mg/day; propafenone - 450-900 mg/day; allapinin - 75-150 mg/day; etacizin - 150-200 mg/day; flecainide - 200-300 mg/day; amiodarone (maintenance dose) - 100-400 mg/day; sotalol - 160-320 mg/day; dofetilide - 500-1000 mcg/day. Verapamil, diltiazem and cardiac glycosides should not be used for anti-relapse therapy of AF and AFL in patients with Wolff-Parkinson-White syndrome (WPS), as these drugs reduce refractoriness additional path atrioventricular conduction and can cause aggravation of the arrhythmia.

In patients with sick sinus syndrome and paroxysms of atrial fibrillation and flutter (bradycardia-tachycardia syndrome), there are expanded indications for implantation of an electrical pacemaker (pacemaker). Permanent pacing is indicated in such patients both for the treatment of symptomatic bradyarrhythmia and for the safe administration of preventive and/or curative antiarrhythmic therapy. To prevent and relieve attacks of AF and AFL in patients without pacemakers, class 1A antiarrhythmics with anticholinergic effects (disopyramide, procainamide, quinidine) can be used. In hypertrophic cardiomyopathy, amiodarone is prescribed to prevent tachyarrhythmia paroxysms, and beta-blockers or calcium antagonists (verapamil, diltiazem) are prescribed to reduce the frequency of ventricular contractions.

As a rule, treatment with antiarrhythmics requires monitoring the width of the QRS complex (especially when class 1C antiarrhythmics are used) and the duration of the QT interval (when treated with class 1A and 3 antiarrhythmics).

Choice of drug for prophylactic antiarrhythmic therapy of paroxysmal and persistent atrial fibrillation and flutter

One can agree with the opinion expressed in international recommendations on the management of patients with atrial fibrillation, according to which anti-relapse therapy in patients without heart pathology or with minimal structural changes should begin with class 1C antiarrhythmics (propafenone, flecainide). Let's add to them domestic drugs of the same class (allapinin and etacizin), as well as sotalol; they are quite effective and devoid of pronounced extracardiac side effects.

Coronary heart disease, especially in the presence of post-infarction cardiosclerosis, and heart failure increase the risk of manifestation of the arrhythmogenic properties of antiarrhythmic drugs. Therefore, treatment of atrial fibrillation and flutter in patients with congestive heart failure is usually limited to the use of amiodarone and dofetilide. While the high efficacy and safety of amiodarone in heart failure and coronary artery disease (including myocardial infarction) has been proven for a long time, similar results for dofetilide were obtained in the recent placebo-controlled studies DIAMOND CHF and DIAMOND MI.

For patients with coronary heart disease, the recommended sequence of prescribing antiarrhythmics is as follows: sotalol; amiodarone, dofetilide; disopyramide, procainamide, quinidine.

Arterial hypertension, leading to hypertrophy of the left ventricular myocardium, increases the risk of developing polymorphic ventricular tachycardia “torsades de pointes”.

It is quite possible that with the emergence of new results from controlled studies on the effectiveness and safety of antiarrhythmic drugs in patients with various diseases of the cardiovascular system, changes will be made to the above recommendations for the prevention of relapses of paroxysmal and persistent AF, since at present the relevant information is clearly insufficient.

If there is no effect from monotherapy, combinations of antiarrhythmic drugs are used, starting with half doses.

The primary task in an attack of the tachysystolic form of AF/AT is to slow down the heart rate, and then, if the paroxysm does not stop on its own, its relief.

Considering the risk of thromboembolism during prolonged paroxysm of AF, the issue of stopping it must be resolved within 48 hours, since if the duration of an attack of AF exceeds two days, it is necessary to prescribe indirect anticoagulants (maintaining the INR at the level of 2.0-3.0) for 3-4 weeks before and after electrical or drug cardioversion. Currently, the most widely used indirect anticoagulants are coumarin derivatives: warfarin and syncumar. If the duration of AF is unknown, the use of indirect anticoagulants before and after cardioversion is also necessary. Similar prevention of thromboembolic complications should be carried out in case of atrial flutter.

For pharmacological cardioversion, the following antiarrhythmics are used:

amiodarone 5-7 mg/kg - intravenous infusion over 30-60 minutes (15 mg/min); ibutilide 1 mg - intravenous administration over 10 minutes (if necessary, repeated administration of 1 mg); novocainamide 1-1.5 g (up to 15-17 mg/kg) - intravenous infusion at a rate of 30-50 mg/min; propafenone 1.5-2 mg/kg - intravenous administration over 10-20 minutes; flecainide 1.5-3 mg/kg - intravenous administration over 10-20 minutes.

The international recommendations for cardiopulmonary resuscitation and emergency cardiac care and the ACC/AHA/ECC recommendations for the treatment of patients with atrial fibrillation note that it is advisable to relieve paroxysm in patients with heart failure or EF less than 40% mainly with amiodarone. The use of other antiarrhythmics should be limited due to the rather high risk of developing arrhythmogenic effects and negative influence these drugs on hemodynamics.

The use of verapamil and cardiac glycosides is contraindicated in patients with AF/AFL and Wolff-Parkinson-White syndrome. In the presence of the latter, AF/AFL is treated with drugs that impair conduction along the Kent bundle: amiodarone, procainamide, propafenone, flecainide, etc.

Oral relief of atrial fibrillation and flutter with quinidine, procainamide, propafenone, flecainide, dofetilide, etc. is possible.

Atrial flutter (type 1) can be relieved or converted to AF by frequent transesophageal or endocardial atrial pacemaker. Stimulation is prescribed for a duration of 10-30 seconds with a pulse frequency that is 15-20% higher than the frequency of atrial contractions, i.e. 300-350 (400) pulses per minute.

When AF/AFL is accompanied by severe heart failure (cardiac asthma, pulmonary edema), hypotension ( systolic pressure less than 90 mm Hg. Art.), increasing pain syndrome and/or worsening myocardial ischemia, immediate electrical pulse therapy (EPT) is indicated.

In case of atrial fibrillation, EIT begins with a discharge with a power of 200 J; for biphasic current, the energy of the first discharge is less. If it turns out to be ineffective, discharges of higher power (300-360 J) are successively applied. Atrial flutter is often relieved by a low-energy shock (50-100 J).

Electropulse therapy can also be chosen for the planned restoration of sinus rhythm in patients with prolonged paroxysms of AF/AFL. Medical cardioversion is recommended if EIT is not possible, undesirable, or fails to restore sinus rhythm. In case of an attack of AF/AFL lasting more than 48 hours, indirect anticoagulants may not be used for a long time before cardioversion if transesophageal echocardiography (TPEchocardiography) excludes the presence of thrombi in the atria (in 95% of cases they are localized in the left atrial appendage). This is the so-called early cardioversion: intravenous administration of heparin (increase in aPTT by 1.5-2 times compared to the control value) or short-term administration of an indirect anticoagulant (bringing the INR to 2.0-3.0) before cardioversion and four weeks of indirect administration anticoagulants after restoration of sinus rhythm. According to preliminary data from the ACUTE multicentre study, the incidence of thromboembolic complications is significantly lower when using TPEchoCG and short courses of preventive therapy with heparin or warfarin (in the absence of a thrombus) or longer-term administration of an indirect anticoagulant (if a thrombus is re-detected after three weeks of warfarin treatment) before EIT than with traditional therapy carried out “blindly” with indirect anticoagulants for 3-4 weeks before and after electrical cardioversion, and is 1.2% and 2.9%, respectively. In patients who do not receive anticoagulants before cardioversion, thromboembolic complications develop in 1-6% of cases.

For severe paroxysms of AF and AFL, refractory to drug treatment, non-pharmacological treatment methods are used: destruction of the AV connection with implantation of an electrical pacemaker, “modification” of the AV connection, implantation of an atrial defibrillator or special pacemakers, radiofrequency catheter destruction of the impulse circulation path in the right atrium during AFL and sources ectopic impulses in patients with focal atrial fibrillation, “corridor” and “labyrinth” operations.

Literature

1. Kastor J. A. Arrhithmias. Philadelphia: W. B. Saunders company 1994. P.25-124.
2. Bialy D., Lehmann M. N., Schumacher D. N. et al. Hospitalization for arrhythmias in the United States: importance of atrial fibrillation (abstr) // J. Am. Coll. Cardiol. 1992; 19:41A.
3. Wolf P. A., Dawber T. R., Thomas H. E., Kannel W. B. Epidemiologic assessment of chronic atrial fibrillation and risk of stroke: the Framingham study // Neurology. 1978; 28: 973-77.
4. The Stroke Prevention in Atrial Fibrillation Study Group Investigators. Stroke prevention in atrial fibrillation study: final results//Circulation. 1991; 84:527-539.
5. Petersen P., Boysen G., Godtfredsen J. et al. Placebo-controlled, randomized trial of warfarin and aspirin for prevention of thromboembolic complications in chronic atrial fibrillation. The Copenhagen AFASAK study // Lancet. 1989; 1:175-179.
6. Biblo L. A., Ynan Z., Quan K. J. et al. Risk of stroke in patients with atrial flutter // Am. J. Cardiol. 2000; 87:346-349.
7. ACC/AHA/ESC guidelines for management of patients with atrial fibrillation//Circulation. 2001; 104:2118-2150.
8. Vorperian V. R., Havighurst T. C., Miller S., Janyary C. T. Adverse effect of low dose amiodarone: a meta-analysis // JACC. 1997; 30:791-798.
9. Bunin Yu. A., Fedyakina L. F., Bayroshevsky P. A., Kazankov Yu. N. Combined preventive antiarrhythmic therapy with etatsizin and propranolol for paroxysmal fibrillation and atrial flutter. Materials of the VII Russian National Congress "Man and Medicine". Moscow, 2000. P. 124.
10. Semykin V.N., Bunin Yu.A., Fedyakina L.F. Comparative effectiveness of combined antiarrhythmic therapy with propafenone, verapamil and diltiazem for paroxysmal fibrillation and atrial flutter. Materials of the VII Russian National Congress "Man and Medicine". Moscow, 2000. pp. 123-124.
11. Sager P. T. New advances in class III antiarrhytmic drug therapy. Curr. Opin. Cardiol. 2000; 15:41-53.
12. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care // Circulation. 2000; 102 (suppl I): I-158-165.
13. Design of a clinical trial for the assessment of cardiversion using transesophageal echocardiography (the ACUTE multicenter study) // Am. J. Cardiol. 1998; 81: 877-883.
14. Bunin Yu. A., Firstova M. I., Enukashvili R. R. Maintenance antiarrhythmic therapy after restoration of sinus rhythm in patients with a permanent form of atrial fibrillation. Materials of the 5th All-Russian Congress of Cardiologists. Chelyabinsk, 1996. P. 28.
15. Bunin Y., Fediakina L. Low doses of amiodarone in preventing paroxysmal atrial fibrillation and flutter. International academy of cardiology. 2nd international congress on heart disease. Abstract book of the congress, Washington, USA, 2001.
16. Gold R. L., Haffajec C. I. Charoz G. et al. Amiodarone for refractory atrial fibrillation // Am. J. Cardiol. 1986; 57:124-127.
17. Miller J. M., Zipes D. P. Management of the patient with cardiac arrhythmias. In Braunwald E., Zipes D., Libby P. (eds). Heart disease. A textbook of cardiovascular medicine. Philadelphia: W. B. Saunders company. 2001. P. 731-736.

www.medcentre.com.ua

What happens with atrial flutter

This arrhythmia occurs due to a disturbance in the conduction of impulses in the heart.

Normally, the impulse propagates through the heart in this way:

With atrial flutter, the impulse flow through the atrial conduction system is disrupted. It begins to circulate in the right atrium in a circle. Because of this, the atrial myocardium is repeatedly re-excited, and they contract at a frequency of 250 to 350 beats per minute.

The ventricular rhythm may remain normal or become faster, but not as fast as the atrial rhythm. This is explained by the fact that the atrioventricular node is not able to conduct impulses so often and begins to conduct only every second impulse from the atria (sometimes every third, fourth or even fifth). Therefore, if the atria contract at a rate of 300 beats/min, the ventricular rate may be 150, 100, 75, or 60 beats/min.

The exception is patients with WPW syndrome. Their heart contains an additional, abnormal bundle (bundle of Kent) that can conduct impulses from the atrium to the ventricle faster than the atrioventricular node. Therefore, atrial flutter in such patients often entails ventricular flutter.

Causes of atrial flutter

Arrhythmia occurs due to heart disease or as a postoperative complication (usually in the first week after heart surgery).

What can trigger an attack in people prone to atrial flutter:

Sometimes paroxysms appear under the influence of the listed negative factors, and sometimes spontaneously.

Symptoms

The attack develops suddenly. During it the patient feels palpitations or discomfort in the heart area. Patients often describe their sensations as “interruptions” in the work of the heart, the heart “rumbles”, “jumps out of the chest.”

Paroxysm is also accompanied by weakness, dizziness, low blood pressure, and sometimes shortness of breath.

Sometimes atrial flutter is asymptomatic (especially if the ventricular rate is normal). But treatment is still necessary, as this arrhythmia can lead to dangerous complications.

Possible complications

The most common:

The last two arrhythmias are very dangerous and can be fatal.

Atrial flutter impairs blood circulation (hemodynamics) in coronary vessels, which entails insufficient blood supply to the myocardium. This can cause a microinfarction, heart attack, or sudden cardiac arrest.

Frequent attacks lead to the development of chronic heart failure.

Also, repeated paroxysms of atrial flutter increase the risk of blood clots, which can lead to:

Diagnostics

It consists of 3 stages:

Initial examination

During an attack, the pulse in the arms may be normal (60–90 beats/min) or increased (up to 150 beats/min). The pulsation of the jugular veins is usually accelerated and corresponds to the frequency of atrial contraction. Blood pressure may be low.

ECG

There are no P waves on the cardiogram. Instead, there are sawtooth F waves preceding the ventricular complexes. The latter are not changed and have no deviations from the norm. Each ventricular complex is preceded by the same number of F waves (2, 3, 4 or 5).

Changes on the cardiogram are visible only during an attack. But since paroxysm can last a long time, it is quite possible to record it using a regular ECG.

If atrial flutter occurs frequently, but the attacks are short-lived, Holter monitoring is prescribed - an ECG using a portable device during the day to “catch” the time of the paroxysm.

Further examination

To prescribe adequate treatment, it is necessary to identify the cause of the arrhythmia.

For this purpose, echocardiography is used. Using this method, heart defects can be diagnosed.

They also do a blood test:

• for thyroid hormones - to identify advanced level thyroid hormones (hyperthyroidism);
• for electrolytes – to diagnose a lack of potassium in the body (hypokalemia);
• for rheumatoid factor - to identify rheumatism (it often causes mitral valve stenosis).

Transesophageal echocardiography is indicated for patients with frequent attacks to check for blood clots in the heart.

Transesophageal electrocardiography helps to establish the exact mechanism of arrhythmia development (exactly how the impulse circulates through the atrium).

How to get rid of the disease

Currently, effective therapy has been developed to relieve attacks of atrial flutter, but this arrhythmia is difficult to cure completely - in many patients, paroxysms appear again. In such cases, radical treatment is used, which helps eliminate the disease forever in 95% of cases.

It is also worth noting that in addition to treating the arrhythmia itself, the underlying disease that contributed to its occurrence is also treated.

Read more about medication and non-drug treatment atrial flutter itself, read on.

Drug relief of paroxysm

It is carried out in 2 stages:

Other methods of stopping an attack

These include:

• Transesophageal pacing (TEPS) is the elimination of arrhythmia using a special pacemaker that is inserted through the esophagus.
• Electrical cardioversion is the restoration of the correct rhythm by applying an electrical discharge to the heart area.

Long-term treatment with medications

Beta blockers or calcium channel blockers may be prescribed to prevent another attack.

To avoid the formation of blood clots, warfarin or aspirin is used.

Radical Methods

If drug treatment does not help, and the arrhythmia still recurs, radiofrequency ablation (destruction by radio frequencies) or cryoablation (destruction-freezing) of the pathways through which the impulse circulates during an attack is prescribed.

They also install a pacemaker that sets the heart correct rhythm.

Prevention

If you are at risk (see the table “Heart diseases that cause atrial flutter” and “Factors that increase the risk of developing this arrhythmia” in the “Causes” section), be sure to adhere to the following rules:

If you have heart failure and have been prescribed diuretics, please contact Special attention at this point, since diuretics remove potassium from the body. But don’t overdo it, since an excess of this element can also cause problems with the cardiovascular system and kidneys. Before adjusting your diet, consult a specialist and, if possible, take a blood test for potassium.

The same rules apply to those who have already experienced this unpleasant phenomenon like atrial flutter. If the attack has been successfully stopped, take all medications prescribed by your doctor and adhere to preventive measures to prevent relapse of the disease.

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What is pathology

Atrial fibrillation and flutter are supraventricular tachycardia and cardiac arrhythmias, leading to paroxysmal tachycardia. Cardiac pathologies, which are sometimes classified as subtypes of atrial fibrillation.

Supraventricular tachycardia, usually called atrial flutter (AFL), is common in men over 60 years of age who already suffer from some type of cardiac pathology, but is difficult to reliably establish in diagnosis and ECG, due to its instability. Severe structural changes in the ventricles and chronic conditions of heart failure sometimes lead to the question of cardiac surgery as the disorder progresses.

Characteristics of pathology and probable signs

A large group of tachyarrhythmias, which include atrial flutter, are pathological disorders of cardiac activity, with a characteristic increase in contraction frequency. The source of the pathological process, located in the atrium, leads to an increase in heart rate several times.

At a normal rate of 60-90 beats per minute, the frequency of contractions during flutter can be 200-300. Maintaining the correct oscillation rhythm is one of the main characteristics that are used in determining a type of atrial fibrillation called atrial fibrillation.

Paroxysm of atrial flutter is the time during which an attack occurs, with a variable duration from a second to lasting several days. Under the influence of treatment, TP quite quickly turns into atrial fibrillation, or sinus rhythm, which was the reason for the lack of a stable determination of the duration of paroxysms.

A permanent form of flutter is an extremely rarely diagnosed pathology, since atrial fibrillation and flutter often replace each other. There are two types of attacks:

• Type 1 (atrial flutter 1) is relieved by electrical stimulation and is characterized by a frequency of 240 to 339 per minute, with F waves displayed in the form of a sawtooth uniform shape;
• Type 2 cannot be interrupted by stimulation, the F-F wave intervals are uneven, the frequency per minute can reach from 340 to 430.

The classification of atrial flutter distinguishes:

• paroxysmal and constant;
• according to types 1 and 2;
• atypical and typical (classical) development of events.

In classical excitation waves, they arise in the right atrium and occur with a flutter frequency of 240 to 340 vibrations per minute. With atypical, circulation can occur in both the left and right atrium, but is accompanied by waves with an oscillation frequency of 340 to 440 vibrations per minute, following an atypical pattern. Based on the place of formation they distinguish:

• right atrial (upper loop and multiple cycle);
• left atrial isthmus-independent flutter.

Classification of pathology according to clinical course

Another division, according to the clinical course, implies:

• first developed;
• paroxysmal;
• persistent;
• permanent.

Paroxysmal form lasts less than 7 days, persistent - more than a week, permanent is said to be when the therapy was not carried out, or was carried out, but did not bring the desired and expected result. An attack can occur once a year or several times a day.

The frequency of occurrence of such cardiac disorders depends on the age, gender and etiological characteristics of each patient. Most often, they affect older men who already have a history of heart pathologies.

Diagnosis of disorders

The only thing that can be determined in this condition by visual inspection is the presence of a rapid pulse, which maintains relative external constancy. When the coefficient is measured frequently, it is discovered that the pulse loses its rhythm.

Clinical symptoms are characteristic of almost any cardiac pathology accompanied by rhythm disturbances. Only the pulsation of the jugular veins, the frequency of which is twice as high as the arterial pulse, but coincides with the rhythm of the atria, gives grounds for a presumptive diagnosis.

An ECG allows you to establish:

• absence of P-waves;
• the presence of unchanged ventricular complexes;
• high frequency;
• sawtooth F-waves.

But the rhythm of ventricular contraction remains correct. To clarify the preliminary diagnosis, a set of diagnostic measures is carried out:

• monitoring of ECG conditions;
• transesophageal echocardiography;
• blood chemistry;
• Ultrasound of the heart;
• electrophysiological study.

If you analyze all the collected diagnostic data, you can establish not only the nature of the pathology, but also its etiological reasons. One of the most common causes is concomitant cardiac dysfunction, which, as a rule, is not always the only one, and requires certain nuances in the treatment of atrial flutter.

Associated symptoms of pathology

Symptoms of cardiac pathology are general, unexpressed, typical for many disorders of the heart. Without a clear clinical picture, such symptoms are taken as signs of a concomitant disease that has already been diagnosed, and the following is observed:

• dyspnea;
• fast fatiguability;
• apathy;
• depressed state;
• decreased physical activity;
• experienced oxygen deficiency during physical effort.

Such symptoms are characteristic of many diseases. Angina pectoris and heart failure are not taken into account as symptoms, but are considered as a certain pathology, most characteristic of excess weight, or a static position due to the nature of professional activity, age, and general physical condition.

Syncope, a pronounced arrhythmia similar to atrial fibrillation, and pain in the chest can also be correlated with existing heart disease. And only diagnosis with a pronounced negative clinical condition, or a routine examination, makes it possible to correlate the perceived arrhythmia with atrial flutter, which can be replaced by it.

Causes of fluttering

Risk factors that appear when collecting a patient’s medical history also do not allow us to trace the presence of clearly manifested patterns.

Only one of them can be identified as general - stressful situations that lead to emotional anxiety, nervous overstrain, and destabilization of the psycho-emotional state.

Other reasons include:

• increased thrombus formation and high blood clotting;
• atherosclerosis, with increased hardening of blood vessels;
• coronary heart disease;
• myocardial infarction;
• heart defects;
• functional defects of the cardiovascular system acquired in fetal development;
• pulmonary pathologies (emphysema or embolism);
• diseases of the endocrinological system (thyroid gland);
• pathological decrease or enlargement of the chambers of the heart;
• chronic diseases of internal organs;
• pathology of the body's metabolic system.

A separate group includes iatrogenic causes (surgeries and surgical interventions). Any of the above reasons can manifest as a separate disease, which is accompanied by cardiac dysfunction, as a consequence of an unhealthy lifestyle.

Eating junk food, disrupting the normal rhythm of sleep, lack of frequency in eating, frequent drinking of alcohol, smoking - all this can cause the development of cardiac pathology, and atrial flutter, as its direct consequence.

Drug treatment

The nature of the course of disorders of the heart, with atrial flutter and fibrillation, is similar in the mechanisms of development and biochemical changes, which implies similar areas of treatment and normalization of the heart rhythm. Both drug and non-drug methods of cardioversion are used. Specialized observations show that drugs are less effective for flutter than for fibrillation.

Relief of flutter is more effective when using radiofrequency ablation or electrical pulse therapy. When it is fundamentally impossible, due to objective reasons, to use these two methods, they are replaced by intravenous infusion of ibutilide. Amiodarone, Sotalol, and other antiarrhythmics show less efficacy than ibutilide (from 38 to 76%) when administered.

To quantitatively reduce the vibrations produced and slow down the rapid heartbeat, the following are used:

• beta blockers, Digoxin, Adenosine;
• Calcium channels are blocked by Diltiazem and Verapamil.

Antiarrhythmics are prescribed according to individual indications, the predominant option is Ibutilide, but the following are also used:

• Sotalol;
• Propafenone;
• Flecainide;
• Amiodarone;
• Dofetilide.

Blood thinners are used for irregular fluttering. Traditional and folk medicine recognizes the effectiveness of homeopathic digitalis preparations in all cases except severe hemodynamic lesions. Digitalis is not very effective for long-term and chronic forms.

In these cases, it is not possible to restore sinus rhythm with the help of a herbal preparation. Novocainamide is also noted, which is also used for fibrillation.

The choice of drugs for drug therapy takes into account the general condition of the patient, the frequency of atrial fibrillation, and the condition of the circulatory system. Most often, Anaprilin, Bisopropol and Metapropol are prescribed, despite the fact that the number of antiarrhythmics produced by the pharmaceutical industry is quite large. Regular use of such drugs is aimed at normalizing sinus rhythm and preventing possible cardiac disorders.

Lifestyle with cardiac pathology

An important method of preventing the occurrence of pathology is diet and the concomitant elimination of any irritating factors. Tea, coffee, sweet carbonated drinks and any alcohol-containing drinks should be excluded from consumption.

The diet is based on fluid restriction, and partial and fractional processes of eating. Products that can cause bloating and flatulence are strictly prohibited. The amount of salt consumed is also limited. The diet is practically salt-free.

The appearance of cardiac arrhythmias requires self-discipline from the patient, regular use of prescribed medications, and caution with any factors that can provoke the progression of the pathology and the appearance of new attacks.

Atrial flutter that is caused by non-cardiac conditions usually resolves by treating the underlying cause of the cardiac disorder. However, a visit to a cardiologist is inevitable if a person wants to maintain a healthy heart.

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Causes and symptoms of flutter

This heart pathology can be caused by several factors, which are mainly diseases of the heart, internal organs and poor lifestyle:

• cardiac ischemia;
• frequent formation of blood clots;
• atherosclerosis (presence cholesterol plaques in vessels);
• consumption of alcohol, certain pharmacological drugs;
• surgical intervention;
• pathological change in the chambers of the heart (enlargement, reduction);
• thyroid diseases;
• disruption of the respiratory system ( pulmonary embolism, emphysema and others);
• myocardial infarction, heart disease;
• chronic diseases;

• pathology of the cardiovascular system during fetal development;
• frequent anxiety and nervous tension.

A greater influence on the occurrence of the disease is exerted by dysfunction of the cardiovascular system (these are all pathologies of the heart), as well as non-compliance with a healthy lifestyle and the presence of excess body weight.

Atrial flutter has symptoms that may indicate cardiac dysfunction and pathology. But often they are not completely noticeable, so the disease proceeds without any symptoms.

Some symptoms may still occur in patients, these are:

• rapid heartbeat;
• shortness of breath, shortness of breath during physical exertion;
• experience, anxiety;
• fainting;
• angina pectoris;
• dizziness;
• malaise, fatigue, apathy;

• pronounced arrhythmia;
• heart failure;
• syncope;
• decreased physical activity, performance;
• pain in the chest area.

For some people, the presence of symptoms may only be apparent during diagnosis or routine cardiac testing.

Diagnosis of the disease

Often, to identify such a disease, an electrocardiogram is used, which shows changes in heart rate and various deviations from the norm. Atrial flutter on an ECG is clearly visible to a cardiologist: based on the study, he can make a diagnosis.

The examination can be performed once or last a whole day - this will help to collect more information about the condition of the heart and analyze its functioning.

In addition, for diagnostic measures, they also use:

• echography to see the moment of dysfunction of the heartbeat;
• ultrasound examination, which helps to assess the condition of the heart, its valves, analyze rhythm and contractions.

It is also important to donate blood for research, which will show abnormalities and indicate the problem, as well as the patients’ own complaints and the occurrence of various symptoms.

All methods are completely safe and necessary for making an accurate diagnosis and developing competent treatment for the disease.

Medical treatment of the disease

This pathology is quite dangerous and can cause some complications, so treatment of atrial flutter must be prompt. Therapeutic actions are carried out by a cardiologist, who makes a diagnosis and prescribes the necessary procedures.

Therefore, the therapy of this disease is divided into the following types:

• drug treatment;
• instrumental influence;
• surgical intervention;
• treatment at home.

These methods are quite effective and can promote recovery in the event of the initial development of pathology and compliance with medical recommendations.

To suppress the symptoms of the disease and restore normal heart rhythm, the patient is prescribed special medications that have these properties and help normalize health.

Several groups of drugs can be prescribed as medications:

1. Antiarrhythmic drugs ensure proper functioning of the heart, stabilize flutters, and lead to normal condition heart rate, and also help suppress the symptoms of the disease and reduce the frequency of their manifestations, thereby normalizing the general state of health. These drugs have many varieties and all kinds of analogues, so medications should be taken at a strictly defined time, on the recommendation of a doctor and under his supervision.
2. Anticoagulants are necessary in order to protect the patient from the occurrence of a dangerous disease - stroke. Therefore, they are prescribed for this pathology, since stroke is one of the complications that can appear at any time. Anticoagulant drugs help normalize heart function, thin the blood to prevent blood clots, and improve heart rate. They should also be taken as directed by the attending physician, following all his recommendations and under supervision.

In addition, medications with magnesium and potassium are prescribed - these are some of the elements that the heart needs for its functioning. proper operation and functioning. Medicines normalize contractions and improve heart rhythm. They must also be prescribed by a cardiologist.

Instrumental and surgical effects

This method of treatment is determined by the use of electric current, which is used to treat patients with a disease such as atrial flutter.

For the procedure to be successful, a special medical device is used - a defibrillator. Treatment is carried out under general anesthesia, but in some emergency situations no anesthesia is performed.

This effect produces a good therapeutic effect, in most cases there is an improvement in the well-being of patients and stabilization of heart rhythms. But it also happens when electric current treatment does not give positive results, and the rhythm disturbance returns again after some time.

In addition, this procedure may pose a risk of developing a stroke, so doctors carry out the necessary procedures in advance, if possible. medical research and appoint medications, subcutaneous and intravenous injections to thin the blood.

Atrial flutter and treatment involves surgery, which in rare cases can be performed. This method is prescribed when severe forms illness or if any complications occur.

The operation is carried out in order to:

• suppress the source of pathology;
• improve the patient's condition;
• stabilize heart rhythm and contraction frequency.

The procedure is done under moderate anesthesia.

First, the doctor establishes the cause of the disease by finding the focal area, then a catheter is inserted, which allows normalizing blood flow and equally distributing electrical impulses.

In most cases, this procedure has a high therapeutic effect and contributes to the patient’s recovery, but there are situations when this treatment does not bring any results.

A condition such as atrial flutter should be accompanied by constant monitoring by the attending physician, and treatment at home is carried out only after the approval of a cardiologist. This therapy consists of simple manipulations that consist of following the doctor’s exact recommendations and taking certain medications prescribed by the cardiologist.

It is also necessary to undergo a medical examination regularly, at regular intervals.

Complications of the disease

If treatment is not timely, as well as in the case of rapid development of this pathology, complications may arise that have a detrimental effect on the patient’s health.

The main complications of atrial flutter are:

• the occurrence of a stroke - manifests itself in a disorder of hematopoiesis, when, due to such a cardiac disease, blood stagnation occurs and a blood clot can develop, getting into the heart, it disintegrates into fine particles and spreads with the bloodstream throughout the body, including to the brain;

• heart failure - manifests itself due to malfunction heart, as a result of insufficient blood pumping, when the rhythm weakens and contractions decrease;
• kidney infarction;
• acute occlusion of mesenteric vessels;
• development of blood clots.

Disease prevention

To prevent the development of atrial flutter and protect yourself from various complications, there are a number of simple preventive measures, which are aimed at improving overall health and reducing the symptoms of the disease.

Prevention of pathology includes the following rules:

• promptly treat cardiac diseases;
• undergo regular medical examinations;

• take the necessary medications prescribed by your doctor;
• lead a healthy lifestyle;
• prevent the development of anxiety and restlessness;
• eliminate caffeine from the diet;
• You cannot take additional medications not prescribed by your doctor;
• Surgical treatment should be performed by experienced, highly qualified medical specialists.

Take any means traditional medicine and other foreign drugs not prescribed by a doctor are undesirable, as this may lead to serious consequences and death of the patient.

Atrial flutter (AF) is one of the supraventricular tachycardias, when the atria contract at a very high speed - more than 200 times per minute, but the rhythm of contractions of the entire heart remains correct.

Atrial flutter is several times more common in men; patients are usually elderly people aged 60 years and older. The exact prevalence of this type of arrhythmia is difficult to determine due to its instability. AFL is often short-lived, so it can be difficult to document it on an ECG and in diagnosis.

Atrial flutter lasts from several seconds to several days (paroxysmal form), rarely more than a week. In the case of a short-term rhythm disturbance, the patient feels discomfort, which quickly passes or is replaced by it. In some patients, flutter and flicker are combined, periodically replacing each other.

The severity of symptoms depends on the speed of atrial contraction: the greater it is, the higher the likelihood of hemodynamic disorders. This arrhythmia is especially dangerous in patients with severe structural changes in the left ventricle and in the presence of chronic heart failure.

In most cases, with atrial flutter, the rhythm is restored on its own, but it happens that the disorder progresses, the heart cannot cope with its function, and the patient needs urgent health care. Antiarrhythmic drugs do not always give the desired effect, so TP is the case when it is advisable to resolve the issue of cardiac surgery.

Atrial flutter is a serious pathology, although not only many patients, but also doctors do not pay due attention to its episodes. The result is expansion of the heart chambers with progressive heart failure, thromboembolism, which can cost life, therefore, any attack of rhythm disturbance should not be ignored, and if it occurs, you should go to a cardiologist.

How and why does atrial flutter occur?

Atrial flutter is a variant of supraventricular tachycardia, that is, the focus of excitation appears in the atria, causing them to contract too frequently.

The heart rhythm during atrial flutter remains regular, in contrast to (atrial fibrillation), when the atria contract rapidly and chaotically. More rare contractions of the ventricles are achieved by partial blockade of impulses to the ventricular myocardium.

The causes of atrial flutter are quite varied, but it is always based on organic damage to cardiac tissue, that is, a change in the anatomical structure of the organ itself. This can be associated with a higher frequency of pathology in older people, while in young people arrhythmias are more of a functional and dysmetabolic nature.

Among the diseases accompanied by TP are:

• Ischemic disease in the form of a diffuse, post-infarction scar or;
• Inflammatory processes in and;
• , especially with a strong one.

There are frequent cases of atrial flutter in patients with pulmonary pathology - chronic obstructive diseases (bronchitis, asthma, emphysema). The expansion of the right chambers of the heart due to increased pressure in the pulmonary artery against the background of sclerosis of the parenchyma and blood vessels of the lungs predisposes to this phenomenon.

After cardiac surgery, the risk of this type of rhythm disturbance is high in the first week. It is diagnosed after correction birth defects, coronary artery bypass grafting.

Risk factors for TP consider diabetes mellitus, disorders electrolyte metabolism, excess hormonal function of the thyroid gland, various intoxications (drugs, alcohol).

As a rule, the cause of atrial flutter is clear, but it happens that the arrhythmia overtakes almost healthy person, Then we're talking about about the idiopathic form of TP. The role of a hereditary factor cannot be excluded.

The mechanism for the appearance of atrial flutter is based on repeated excitation of atrial fibers of the macro-re-entry type (the impulse seems to go in a circle, involving into contraction those fibers that have already contracted and should be relaxed at this moment). “Re-entry” of the impulse and excitation of cardiomyocytes is characteristic of structural damage (scar, necrosis, inflammation), when an obstacle is created to the normal propagation of the impulse along the fibers of the heart.

Having arisen in the atrium and causing repeated contraction of its fibers, the impulse still reaches the atrioventricular (AV) node, but since the latter cannot conduct such frequent impulses, at most half of the atrial impulses arise - at most - half of the atrial impulses reach the ventricles.

The rhythm remains regular, and the ratio of the number of contractions of the atria and ventricles is proportional depending on the number of impulses conducted to the ventricular myocardium (2:1, 3:1, etc.). If half the impulses reach the ventricles, the patient will have tachycardia up to 150 beats per minute.

atrial flutter moving from 5:1 to 4:1

It is very dangerous when all atrial impulses reach the ventricles, and the ratio of systoles of all parts of the heart becomes 1:1. In this case, the rhythm frequency reaches 250-300, hemodynamics are sharply disrupted, the patient loses consciousness and signs of acute heart failure appear.

AFL can spontaneously develop into atrial fibrillation, which is not characterized by a regular rhythm and a clear ratio of the number of ventricular to atrial contractions.

In cardiology, there are two types of atrial flutter:

typical and reverse typical TP

1. Typical
2. Atypical.

In a typical case In case of TP syndrome, the excitation wave travels through the right atrium, the systolic frequency reaches 340 per minute. In 90% of cases, contraction occurs around the tricuspid valve counterclockwise, in other patients it occurs clockwise.

At atypical form TP the wave of myocardial excitation does not pass in a typical circle, affecting the isthmus between the mouth of the vena cava and the tricuspid valve, but along the right or left atrium, causing contractions up to 340-440 per minute. This form cannot be treated with transesophageal pacing.

Manifestations of atrial flutter

In the clinic it is customary to highlight:

• New atrial flutter;
• Paroxysmal form;
• Constant;
• Persistent.

At paroxysmal In this form, the duration of TP is no more than a week, the arrhythmia resolves spontaneously. persistent the course is characterized by a duration of disturbance of more than 7 days, and independent normalization of the rhythm is impossible. ABOUT constant form it is said when an attack of fluttering cannot be stopped or no treatment was carried out.

It is not the duration of AFL that is clinically important, but the frequency with which the atria contract: the higher it is, the more obvious the hemodynamic disturbance and complications are more likely. With frequent contractions, the atria do not have time to provide the ventricles with the required volume of blood, gradually expanding. With frequent episodes of atrial flutter or a permanent form of pathology, circulatory disorder occurs in both circles and dilated cardiomyopathy is possible.

In addition to insufficient cardiac output, important also has a lack of blood going to coronary arteries. With severe AFL, the lack of perfusion reaches 60% or more, and this is the likelihood of acute heart failure and heart attack.

Clinical signs of atrial flutter appear during paroxysmal arrhythmia. Patients' complaints include weakness, fatigue, especially during exercise, discomfort V chest, rapid breathing.

With a deficiency of coronary circulation, symptoms appear; in patients with coronary heart disease, the pain intensifies or is progressive. The lack of systemic blood flow contributes to hypotension, then dizziness, darkening of the eyes, and nausea are added to the symptoms. A high frequency of atrial contractions can provoke syncope and severe fainting.

Attacks of atrial flutter more often appear in hot weather, after physical exertion, or strong emotional experiences. Alcohol intake, errors in diet, and intestinal disorders can also provoke paroxysms of atrial flutter.

When there are 2-4 atrial contractions per ventricular contraction, patients have relatively few complaints; this ratio of contractions is more easily tolerated than atrial fibrillation, because the rhythm is regular.

The danger of atrial flutter is its unpredictability: at any moment, the frequency of contractions can become very high, palpitations will appear, shortness of breath will increase, and symptoms of insufficient blood supply to the brain will develop - dizziness and fainting.

If the ratio of atrial to ventricular contractions is stable, the pulse will be rhythmic, but when this ratio fluctuates, the pulse will become irregular. A characteristic symptom will also be pulsation of the veins of the neck, the frequency of which is two or more times higher than the pulse in the peripheral vessels.

As a rule, TP appears in the form of short and infrequent paroxysms, but with a strong increase in contractions of the heart chambers, complications are possible - thromboembolism, pulmonary edema, acute heart failure, ventricular fibrillation and death.

Diagnosis and treatment of atrial flutter

In the diagnosis of atrial flutter, electrocardiography is of paramount importance. After examining the patient and determining the pulse, the diagnosis can only be speculative. When the ratio between contractions of the heart is stable, the pulse will be either more frequent or normal. If the conduction coefficient fluctuates, the rhythm will become abnormal, as with atrial fibrillation, but it is impossible to distinguish these two types of disorders by pulse. In the primary diagnosis, assessment of the pulsation of the neck veins, which exceeds the pulse by 2 or more times, helps.

ECG signs of atrial flutter consist of the appearance of so-called atrial F waves, but the ventricular complexes will be regular and unchanged. During daily monitoring, the frequency and duration of TP paroxysms and their relationship with exercise and sleep are recorded.

Video: lesson on ECG for non-sinus tachycardias

To be sure anatomical changes in the heart, diagnosing the defect and determining the location of organic damage is carried out, during which the doctor specifies the size of the organ cavities, the contractility of the heart muscle, and the characteristics of the valve apparatus.

Laboratory tests are used as additional diagnostic methods - determination of the level of thyroid hormones in order to exclude thyrotoxicosis, rheumatic tests for rheumatism or suspicion of it, determination of blood electrolytes.

Treatment of atrial flutter can be medication or cardiac surgery. A great difficulty is the resistance of TP to drug effects, in contrast to flicker, which can almost always be corrected with drugs.

Drug therapy and first aid

Conservative treatment includes prescribing:

• (metoprolol);
• (verapamil, diltiazem);
• Antiarrhythmic drugs (amiodarone, flecainide, ibutilide);
• Potassium preparations;
• (digoxin);
• (warfarin, heparin).

Beta blockers, cardiac glycosides, calcium channel blockers are prescribed in parallel with antiarrhythmics in order to prevent improvement of conduction in the atrioventricular node, since there is a risk that all atrial impulses will reach the ventricles and provoke ventricular tachycardia. Verapamil is most commonly used to control ventricular rate.

If paroxysm of atrial flutter occurs against a background when conduction along the main pathways of the heart is impaired, all drugs from the above groups are strictly contraindicated, except for anticoagulants and antiarrhythmic drugs.

Emergency care for paroxysm of atrial flutter, accompanied by angina pectoris, signs of cerebral ischemia, severe hypotension, and progression of heart failure consists of: emergency electrical cardioversion with low power current. In parallel, antiarrhythmics are administered to increase the effectiveness of electrical stimulation of the myocardium.

Drug therapy for an attack of flutter is prescribed if there is a risk of complications or poor tolerability of the attack, and amiodarone is injected into a vein. If amiodarone does not restore the rhythm within half an hour, cardiac glycosides (strophanthin, digoxin) are indicated. If there is no effect from the drugs, electrical cardiac stimulation is started.

Another treatment regimen is possible for an attack whose duration does not exceed two days. In this case, procainamide, propafenone, quinidine with verapamil, disopyramide, amiodarone, and electrical pulse therapy are used.

If appropriate, transesophageal or intraatrial myocardial stimulation is indicated to restore sinus rhythm. Exposure to ultrahigh frequency current is carried out for patients who have undergone heart surgery.

If atrial flutter lasts more than two days, then before starting treatment, anticoagulants (heparin) must be administered to prevent thromboembolic complications. For three weeks of anticoagulant therapy, beta blockers, cardiac glycosides, and antiarrhythmic drugs are prescribed in parallel.

Surgical treatment

RF ablation for AFL

In case of persistent atrial flutter or frequent relapses, the cardiologist may recommend a test that is effective in the classic form of atrial flutter with circular circulation of the impulse through the right atrium. If atrial flutter is combined with sick sinus syndrome, then in addition to ablation of the conduction pathways in the atrium, the atrioventricular node is also exposed to the current, and subsequently, ensuring the correct heart rhythm.

Resistance of atrial flutter to drug treatment leads to increasingly frequent use radiofrequency ablation (RFA), which is especially effective in the typical form of pathology. The action of radio waves is directed to the isthmus between the mouth of the vena cava and the tricuspid valve, where the circulation of the electrical impulse most often occurs.

RFA can be performed both at the time of paroxysm and as planned during sinus rhythm. The indication for the procedure will be not only a prolonged attack or severe course TP, but also the situation when the patient agrees to it, because long-term use conservative methods may provoke new types of arrhythmias and is not economically feasible.

Absolute indications for RFA– lack of effect from antiarrhythmic drugs, their unsatisfactory tolerability, or the patient’s reluctance to take any medications for a long time.

A distinctive feature of TP is its resistance to drug treatment And high probability recurrence of flutter attacks. This course of pathology greatly predisposes to intracardiac thrombus formation and the spread of blood clots in a large circle, resulting in strokes, intestinal gangrene, infarctions of the kidneys and heart.

The prognosis for atrial flutter is always serious, but depends on the frequency of arrhythmia paroxysms and duration, as well as on the speed of atrial contraction. Even with a relatively favorable course of the disease, one cannot ignore it or refuse the proposed treatment, because no one can predict what strength and duration the attack will be, and, therefore, the risk dangerous complications and death of the patient from acute heart failure during LT is always possible.

Video: atrial flutter, program “Live Healthy!”

One of the presenters will answer your question.

Currently answering questions: A. Olesya Valerievna, Ph.D., teacher at a medical university