Download The Alternation Atrial Flutter and Atrial Fibrillation* `

The Alternation
between
Atrial Fibrillation*
M.D.;
Paul A. Tunick,
Itzhak
Kronzon,
Atrial Flutter
Teresa
McElhinney;
L4llian
Mitchell,
fibrillation
and
trant mechanism.
trial fibrillation
is a common
is seen in 2 to 4 percent
60
years
of
0.4
7 to
12
po’
and
myocardial
and
M.D.
atrial
flutter
share a common
reenHowever,
the relationship
between
these
arrhythmias
has not been systematically
studied
to date. To
evaluate
the degree
to which
these
arrhythmias
may
alternate,
consecutive
Holter
monitor
recordings
which
showed fibrillation
or flutter in 96 patients
were
reviewed.
One half of the patients
were studied
after open-heart
surgery
and the other half for varying
indications.
One
quarter
of the patients
had atrial
flutter
in addition
to
Atrial
B.A.;
infarction.3
It
mitral
cardiac
arrhythmia.
of patients
greater
percent
of the
10 percent
of
patients
with
(present
identified
in 90 percent).3
as an arrhythmia
is especially
stenosis
who
It
had
and this alternation
with flutter was significantly
with the use of a type 1A antiarrhythmic
drug
(p =0.007),
but not with the use of digoxin or beta blockers
= NS for both).
Furthermore,
this alternation
with flutter
was more common
in the postoperative
group
(p
0.01). A
history of embolization
was less common
in patients
who
were in the postoperative
group
(p
0.003) and patients
who had flutter in addition to fibrillation
(p 0.05).
(Chest
1992; 101:34-36)
(p
‘
following
open-heart
in
digoxin
were
blockers.
patterns
(ftbrillation
systematically
studied
thus far. In order to
the relationship
between
these
arrhythmias,
consecutive
Holter
monitor
recordings
which
showed
atrial
fibrillation
or flutter
or both in 96
AF1:
PAFI:
Paroxysmal
sinus
rhythm.
Comb:
6.
underwent
Of
ambulatory
these,
atrial
96
The
Bonke,
(10
and/or
two
with
(Holter)
atrial
atrial
flutter
fibrillation
activity
in the
form
of small
waves
that
Atrial
flutter
showed
of the
atria
oscillations
(200
in fibrillation
flutter
the
fixed
multiples.
the
R-R
96 patients,
with
or without
additional
defined
‘
half
(48)
.
highly
.
.
with
In addition,
as appearing
studied
during
regular
regular
Groups
A
compared
the
Department
Center,
New York.
Manuscript
received
Reprint
requests:
Dr
New York 10016
34
of Medicine,
New
and
use
rhythms
B
There
recording.
fibrillation
on the
with
entire
flutter
and
and
alternat-
combined
recording.
alternating
flutter,
no sinus
with
with
alternation
rhythm
present.
fibrillation
fibrillation,
(postoperative
and
flutter
flutter,
and
sinus
the
and
chi
and
nonpostoperative)
square
a p value
test
(age
of 0.05
were
was
was
compared
considered
to
significant.
Mar
flutter
by
of a t test),
ECG
using
patient’s
recordings
a two-lead
Avionics
were
noted.
physician
and
All
two
of the
numberand
done
(V, and
Trendsetter.
by at least
The
were
system
Clinical
from
on a reel-to-reel
V1) and
were
arrhythmias
authors
duration
including
information
on
reviewed
at least
ofatrial
was
tape
scanned
were
ofperiods
the hospital
one
fibrillation
obtained
from
the
chart.
RESULTS
. .‘.
and
The
rhythm
men
biphasic
while
in regular
hospitalization
York University
1C drug.
on the entire
with
flutter,
between
in
or
entire
study
group
and 36 women.
years
old,
were
47 patients
with
Medical
May 6; revision
accepted
July 23.
Tunick,
NYU Medical
Center,
560 Fl rat Avenue,
Their
with
with mitral
valve
three
congenital
with
and
There
demonstrable
ages
age
ranged
of 67
heart
and
one
12 patients
Mernation
with
±
14 to 90
11 years.
There
aortic
two
sick
sinus
atrial
cardiac
disease,
valve
disease,
with
60
from
heart
17 with
endocarditis,
heart
of 96 patients,
atherosclerotic
disease,
hypertension,
were
consisted
an average
cardiomyopathy,
*Fmm
on a type
present
Paroxysmal
statistically
the
and
the ventricular
irregular
IA
uncoordi-
activation
in amplitude
as irregularly
defined
were
vary
sinus
to Allessie
and
atrial
“rapid,
shape.”
defined
were
“chaotic
irregular
beats/minute)
was
according
constantly
ofuniform
intervals
Comb:
alternations
and classified
cardiologist.
showed
type
or disopyrimide),
rhythm.
a Del
laboratory.
which
“completely
to 350
(F waves)
response
Oi
with
in our
recordings
showing
atrial
patients
had
were
nated”
configuration.”
recordings
percent)
arrhythmias
consecutive
of valve
with
as follows:
fibrillation
two
Parox
High-fidelity
of 992
was
present
atrial
with
recorder
a total
ECG
patients
fibrillation
rhythm.
and
period,
treatment
fibrillation,
flutter,
Combined
the
clinical
for the presence
and
ofarrhythmia
atrial
between
be statistically
METHODS
a three-month
Fixed
A. The
other
rhythm.
4.
with
reviewed.
sinus
as group
for various
procaineamide
atrial
3.
5.
analyzed
fibrillation,
atrial
ing with
arrhythmias
were
No patient
Paroxysmal
PAF:
designated
phenomena
(quinidine,
and beta
2.
were
studied
groups
drugs
1. AF:’Fixed
Atrial flutter
has long been
separate
from fibrillation,4
and
B, were
of embolic
six differing
not been
determine
Over
two
history
antiarrhythmic
being due to random
reentry
and flutter being due to
nonrandom
localized
reentry).
However,
the degree
to which
these
arrhythmias
coexist
or alternate
has
were
group
The
disease,
emboli
surgery
48 patients,
indications.
adult
with
common
have
fibrillation,
associated
other
than
general
patients
but it has been
believed
that the two
share a similar macro reentrant
mechanism
patients
and
21
disease,
each
with
syndrome
amyloidosis.
fibrillation
and
no
disease.
between
Atrial Flutter
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21638/ on 05/03/2017
and FibriliatlOn (Tursick a! a!)
Arrhythmia
seven with aortic valve disease,
disease,
two without
associated
Classification
Most
of
the
fibrillation,
patients
either
(83,
alone
86
or with
percent)
sinus
or both.
The
six differing
patterns
occurred
as follows:
1 . AF: 42 patients
(44 percent).
2.
PAF:
17 patients
(18 percent).
3.
AF1: 6 patients
4.
5.
PAF1:
Comb:
had
rhythm
of
atrial
with
or flutter,
arrhythmia
of the
(7 percent).
(4 percent).
6. Parox Comb:
20 patients
(21 percent).
Postoperative
vs Nonpostoperative
(Group
A vs B):
The groups
were of equal size (48 patients
each), and
the postoperative
(64.6 vs 69.7 years
tive
patients
(group
disease
(p
the following
Parox
0.02),
types
=
Comb
to have
patients
old, p
(p
A) were
more
of atrial
(p = 0.0002)
and a history
There
was no statistically
other types of arrhythmia
1A antiarrhythmic
drug,
groups
Alternating
A and
Flutter
There
were
24
to have
there
flutter
valve
was
in this
patients
fixed
atrial
a trend
group
also
in group
fibrillation
B
of embolization
(p = 0.003).
different
incidence
of the
or of treatment
with a type
digoxin
or beta
blocker
with
alternation
between
fibrillation
and flutter, which included
20 patients
with
Parox Comb (some sinus rhythm)
and four with Comb
(no sinus rhythm).
Of these
24, 17 (71 percent)
were
in group
were
A (postoperative)
14 patients
with
time
average
flutter
episodes
and seven
in group
atherosclerotic
heart
1-Clinical
.
B There
disease,
and ECG
Data
GroupB
p Value
N
48
48
NS
Age
64.6
69.7
0.03
AF(42)
12
30
0.0002
PAF(17)
13
4
AF1(6)
2
4
NS
PAFI(7)
4
3
NS
Comb(4)
2
2
NS
Comb
(20)
0.02
15
5
AnyAF(83)
42
41
Any
23
14
0.06
AF1 (37)
Emboli(17)
0.01
NS
3
14
0.003
TypeIARx(33)
18
15
NS
Digoxin
33
27
NS
-Blocker(28)
15
13
NS
Valve
23
12
AF
Rx (60)
dis (35)
=
atrial
fibrillation
fibrillation;
combined
fibrillation;
and
AF1
flutter,
PAF1
atrial
no
atrial
sinus
paroxysmal
fibrillation,
atrial
0.02
flutter;
COMB
combined
rhythm;
PAF
paroxysmal
atrial
flutter;
flutter,
and
with
sinus
Parox
rhythm
atrial
atrial
Comb
in flutter
(range,
0. 1 to 99.9
percent).
In
recording
only one);
patients
with alternating
flutter
and fibrillation
or without
sinus
rhythm)
had an average
episodes
of flutter
having
only
Drug
Therapy
of
(range,
1 to 45,
with
of
(with
five
12 patients
one).
IA antiarrhythmic
A type
time
of the recording
note,
13 of the
and
Parox
agent
in 33 of96
24 patients
Comb
was
in use
at the
patients
(34 percent).
(54 percent)
in the
groups
were
on
a type
IA
agent during
the recording.
Only 14 of 59 patients
(24
percent)
who had fibrillation
and no flutter
(AF and
PAF) were
on a type
IA antiarrhythmic
drug.
This
difference
was statistically
significant
(p = 0.007).
There were no significant
differences
between
patients
with
Comb
and
Parox
Comb
vs patients
PAF with
respect
to the use
blockers
(p = NS for both). Thus,
associated
the type
GroupA
Parox
one cardiac
in patients
of flutter
on their
ambulatory
1 to 15, with five patients
having
fibrillation,
Table
than
flutter
of nearly
twice
as much time (35 percent)
in
(range,
3 to 89 percent).
The
number
of
of flutter
per patient
was similar
in those
Comb
Fibrillation
patients
had more
of atrial
contrast,
the duration
of atrial flutter
in the patients
with PAF1 was almost twice as long, averaging
497 mm
(range,
45 to 1,406 mm), and these
patients
spent an
episodes
(range,
B.
and
(three
duration
with combined
flutter
and fibrillation
and those
with
just PAF1: patients
with PAF1 had an average
of three
more likely to have
PAF (p = 0.02) and
Statistically
(p = 0.06).
The nonpostoperative
were
more
likely
to have
between
likely
and they were
ofarrhythmias:
0.01).
type
any
were
somewhat
younger
0.03 [Table 1]). Postopera-
=
The
alternating
flutter
and
fibrillation
(with
or without
sinus
rhythm)
averaged
255 mm (range,
1 to 1,369
mm) and these patients
spent an average
of 19 percent
(6 percent).
7 patients
4 patients
cardiomyopathy
disease).
three with mitral valve
heart disease
and one
with
of digoxin
in patients
AF and
and
with
beta
atrial
the use ofa type IA drug was significantly
with alternation
with atrial flutter.
However,
IA drugs may have been prescribed
because
of rhythms
which
are
paroxysmal
and
therefore
pre-
sumably
more likely to be chemically
cardiovertable,
and paroxysmal
arrhythmias
may
have
more
of a
propensity
to alternate.
Therefore
the drugs may not
be responsible
There
was
for the alternation.
no significant
difference
type 1A drug between
A) and nonpostoperative
in the
postoperative
patients
patients
(group
B),
use
of a
(group
18 vs 15
patients,
nor was there any difference
between
these
two groups
in the use of digoxin
(33 vs 27 patients)
or
beta
blockers
HLstory
(15 vs 13 patients
[p
=
NS for both]).
of Embolization
There
was a history
of stroke
or peripheral
zation
in 17 of 96 patients
(18 percent).
incidence
could be due to selection
bias,
with
emboli
may
have
been
referred
emboliThis high
since patients
for Holter
monitoring.
CHEST
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21638/ on 05/03/2017
I 101 I 1 I JANUARY,
1992
35
Emboli
and
Arrhythmias
Of these
17, 11 were in the AF group,
PAF group and three
in the Parox Comb
one of whom
was in the postoperative
history
of embolization
was
statistically
three in the
group (only
group
A). A
more
be present
in patients
with fibrillation
atrial
flutter
[p = 0.05]).
There
were
patients
with a history
of embolization
and only three
of 17 in the postoperative
This
relationship
was also statistically
(p
=
likely
to
alone (without
14 of the 17
in group
group
significant
B,
A.
and
There
was
Cardiac
a high
Diagnosis
incidence
of history
of emboliza-
due to selection
bias. Of the 36 patients
disease,
only 3 (8 percent)
had a history
This represented
embolization.
disease
history
is not surprising
and hemodynamic
be
uncommon
mias. This
to a history
between
valve
disease
may
The
make
high
with
AF
and
has
had
a
Patients
riods
believed
to be
due
to
multiple
dium.5
reentry,
reentrant
circuits
within
the atrial myocarSimilarly,
atrial flutter
is thought
to be due to
and Olshansky
et al6 have
demonstrated
reentry
flutter.6
rhythms
and an area ofslow
conduction
in human
atrial
It is therefore
not surprising
that the two
may occur
in the same patients,
and in fact
the presence
sinus rhythm
time
of atrial
in differing
has been
showed
treated
shown
fibrillation,
atnal
parts of the atria
in a patient
whose
flutter
at the
given
sure
whether
effects
of the
ECG
have
with a
36
have
mon in patients
fibrillation.
1 Kerr
CR,
future.
Chung
Clin
Bonke
WJ,
ed.
not
of the
coinci-
higher
nature
and
nosis
4 Jolly
a
a signifi-
the patients
in
patients
had a
incidence
of Parox
Comb.
The
of the arrhythmias
in the postop-
Atrial
pewith
prove
that
since
these
ofthe
nature
are more
is relatively
and
1911;
2:177
5 Waldo
AL.
ectopic
Acts
Med
FIM.
Bitchie
likely
to
uncom-
to their
fact,
1985;
atrial
Atrial
Auricular
of atrial
tachycardia-a
a review
arrhythmias:
basic
their
of course
and
fibrillation,
review.
concepts.
In:
mechanisms,
Lippincott,
flutter
brief
and
216:5-9
Philadelphia:
WT
controversy
3:319-37
fibrillation:
1984;
arrhythmias:
Mechanisms
atrial
Atrial
Scand
Cardinc
management.
WA,
fibrillation:
Pacing
J.
P, Godtfredsen
prognosis.
diag-
1987:186-207
fibrillation.
atrial
Heart
flutter,
Circulation
1987;
and
75-
111:37-40
6 Olshansky
B, Okumura
of an area
and
not
in addition
Electrophysiol
MA,
of PAF
have
alternation
because
which
also
flutter
DC.
Prog
Mandel
incidence
(50
neurologists
REFERENCES
3 Allessie
higher
prescribed
with
were
A had
This
this does
alternation,
arrhythmias,
Embolization
they
lower
incidence
of AF than
B. In addition,
the postoperative
significantly
paroxysmal
been
may
group),
group
disease
from
of the patients’
arrhythmias,
while
digoxin
and beta
blockers
may have been
prescribed
for more
stable
rhythms.
Alternation
with flutter
is more common
in
(no control
such patients
in our study.
The patients
in the postoperative
significantly
drugs
2 Petersen
because
flutter
was
in
with
the use of type
IA
not with the use of digoxin
However,
caused
the
percent).
were
not
flutter
occurred
or whether
the
may
which
which
commonly
as well.
or beta blockers.
type
IA drugs
(17
who
the
drug
heart
fibrillation
is associated
drugs,
but
therapy
patients
dental,
since patients
with atrial fibrillation
also may
develop
flutter independent
oftherapy.
We have shown
that atrial flutter
is common
in patients
who also have
atrial fibrillation,
and it was seen
in one quarter
of
cantly
group
atrial
flutter
propafenone
not have any
propafenone
demonstrable
reflects
referrals
specialists.
with
postoperative
be paroxysmal.
type IC agent,
propafenone.
In 13 of their patients
(16 percent)
atrial flutter
as well as fibrillation
had
been
documented,
and atrial flutter
occurred
in 14
patients
during
Since
they did
This
patients
following
open-heart
surgery.
A history
of
embolization
is relatively
uncommon
in patients
with
and
same
surface
atrial flutter.7
Murdock
et al8 recently
82 patients
who had atrial fibrillation
flutter.
flow and clot formation
less likely.
of embolization
in the patients
no
atrial
of
antiarrhythmic
been
and
effective
atnal contractions
and not during
fibrillation,
stagnant
incidence
atrial flutter
fibrillation
was
arrhythand tran-
CONCLUSION
DISCUSSION
Atrial
this
with postoperative
reflects
the acute
fibrillation
to the
flutter
18 percent
of the 17 patients
of them had mitral valve
aortic
acute
occur
sient nature
of the arrhythmias
in the postoperative
setting.
Furthermore,
a history
of embolization
was
more common
in patients
who had atnal fibrillation
without
flutter
than in those who experienced
alter-
All three
(no patient
with
of embolization).
of the
which
of embolization,
in the patients
probably
also
percent)
probably
and rehabilitation
with valve
of emboliza-
in view
changes
patients.
With respect
part be due
occur during
tion in the patients
with AF and no demonstrable
heart disease,
6 of 12 (50 percent),
which
also may
tion.
with
in such
nation
0.003).
Emboli
erative
group
inflammatory
of slow
K, Hess
conduction
PG,
Waldo
in human
AL.
Demonstration
atrial
flutter.
JACC
1990;
Gough
WB,
El-Sharif
16:1639-48
7 Gomes
JAC,
Kang
Coexistence
Circulation
1981;
8 Murdock
brugge
fibrillation
PS,
of sick
CJ,
S,
with
M,
rhythm
and
atrial
N.
flutter-fibrillation.
63:80-86
Kyles
Kerr
Matheson
sinus
CR.
AE,
Yeung-Lai-Wah
Atrial
propafenone.
Alternation
between
flutter
Am
JA, Anzhen
in patients
J
Cardiol
AIdaI Flutter
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21638/ on 05/03/2017
Q,
treated
1990;
Vorderfor
atrial
66:755-57
and AbililatiOn
(Tunick eta!)