Atrial Flutter and Atrial Fibrillation Nursing Guide

This course is intended as a Quick Reference for atrial flutter and atrial fibrillation and will cover an overview as well as nursing considerations utilizing the nursing process.

Atrial Flutter & Atrial Fibrillation Etiology and Epidemiology 

Atrial fibrillation and atrial flutter are both supraventricular tachyarrhythmias. This means that they occur from electrical impulses before the impulse reaches the ventricles. Cardiac remodeling within the atria is the cause of atrial fibrillation and atrial flutter. There are three types of atrial fibrillation which are (Nesheiwat et al., 2023):

• Paroxysmal, which converts to regular cardiac rhythm within 7 days.
• Persistent, which lasts longer than 7 days but responds to cardioversion.
• Permanent, which does not respond to treatment.

Atrial fibrillation (AF) is the most common cause of stroke with a cardiac origin (Nesheiwat et al., 2023). In atrial fibrillation, the atria quiver instead of contracting fully and the ventricles and atria do not work together as they normally do. This leads to the ventricle’s not filling and not pumping blood effectively. This inadequate pumping often leads to blood pooling in the heart chambers, thus increasing the risk of stroke.

Atrial flutter is a heart rhythm disturbance that causes the atria to beat at a rapid rate of up to 400 atrial beats per minute (Rodriguez Ziccardi et al., 2021). Because the same signal causing the atria to beat rapidly does not reach the ventricles, the ventricular rate is slower than the atrial rate. There will be several atrial contractions for one ventricular contraction.

Atrial fibrillation is the most common cardiac dysrhythmia and atrial flutter is the second most common (Nesheiwat et al., 2023). Globally, the incidence of atrial fibrillation has been increasing. Atrial flutter is often associated with individuals who also have atrial fibrillation, and therefore the rates of atrial flutter are also increasing. The number of individuals with atrial fibrillation will likely double or triple by 2050. Atrial fibrillation is found in approximately 9% of individuals over 75 and atrial flutter has a similar age-related increase in incidence. Atrial flutter is more common in men and individuals with chronic obstructive pulmonary disease, pulmonary hypertension, and heart failure.

Some risk factors are the same for atrial fibrillation and atrial flutter; however, many are not. Risk factors for atrial fibrillation include:

• Alcohol and illicit drug use
• Neurological disorders
• Inflammation
• Advanced age
• Endocrine disorders
• Ischemia
• Genetic factors

Risk factors for atrial flutter include:

• Alcohol overuse
• Diabetes mellitus
• Hypertension

Atrial fibrillation can be one of the causes of atrial flutter. There are more causes of atrial fibrillation than for atrial flutter. Causes of atrial fibrillation include (Nesheiwat et al., 2023):

• Cardiac abnormalities:
  • Mitral or aortic valve stenosis or regurgitation
  • Cardiomyopathy
  • Malignancy involving the atrium
  • Atrial septal defect
• Conduction abnormalities:
  • Tachy-brady syndrome
  • Wolff-Parkinson-White (WPW) syndrome
  • Short QT syndrome
• Functional abnormalities:
  • Myocardial infarction
  • Pericarditis
  • Pulmonary embolism
  • Coronary artery disease
  • Rheumatic heart disease
  • Hypertension
• Metabolic conditions:
  • Carbon monoxide poisoning
  • Hypoxemia
  • Hypokalemia
  • Hypomagnesemia
  • Hypercalcemia
• Medications:
  • Theophylline (Theochron®)
  • Albuterol (Ventolin®)
  • Tricyclic antidepressants (Elavil®, Pamelor®)
  • Digoxin (Lanoxin®)
  • Ophthalmic atropine (Ocu-Tropine®)
  • Sympathomimetics (ephedrine/Ephedra®)
  • Adenosine (Adenocard®)
  • Nicotine
• High adrenaline state:
  • Hyperthyroidism
  • Obstructive sleep apnea
  • Hypoglycemia
  • Pheochromocytoma
  • Drug or alcohol withdrawal
  • Post-operative period

Causes of atrial flutter include (Rodriguez Ziccardi et al., 2021):

• Prior atrial surgery (valve replacement)
• Treatment for atrial fibrillation such as radiofrequency catheter ablation
• Atrial remodeling from:
  • Heart failure
  • Valvular disease
  • Hypertension
  • Pneumonia
  • Sleep apnea

Atrial Fibrillation ICD-10 Code (chronic atrial fibrillation, unspecified): I48.20

Atrial Flutter and Atrial Fibrillation Diagnosis

Diagnosis for atrial fibrillation begins with a thorough history and physical followed by an electrocardiogram (ECG) (Nesheiwat et al., 2023). Criteria found on ECG to diagnose atrial fibrillation includes:

• Performed while arrythmia is occurring
• Rapid fibrillating baseline waves of varying amplitude, shape, and timing
• Absence of P waves
• Irregularly irregular ventricular response (R to R interval)

Once an ECG is done, other testing should be completed such as:

• Transesophageal echocardiogram (TEE) to rule out left atrial thrombus
• Blood tests:
  • Troponin I
  • CPK
  • B-type natriuretic peptide
  • Serum electrolytes
  • Renal function tests
  • Liver function tests
  • Complete blood count
  • Coagulation panel
  • Fasting lipid profile
  • Fasting glucose
  • D-Dimer
• Spiral computed tomography scan to rule out pulmonary embolism
• Chest x-ray to look for pulmonary abnormalities or heart enlargement
• Ambulatory (Holter) monitor for asymptomatic patients
• Exercise treadmill testing
• Electrophysiology studies for curative ablation
• Sleep study for individuals with obstructive sleep apnea or advanced heart failure
• Doppler echocardiogram to assess for:
  • Cardiac dimensions
  • Cardiac function
  • Valvular or pericardial disease
  • Thromboembolism
• Transthoracic echocardiogram to assess for:
  • Left atrial volume
  • Left atrial dilation
  • Systolic and diastolic function
  • Ventricular size and thickness
  • Structural heart disease
  • Right heart function
  • Ventricular and pulmonary artery pressures
  • Congenital or septal defects

To diagnose atrial flutter, a history and physical should be done to include prior episodes of atrial fibrillation (Rodriguez Ziccardi et al., 2021) . ECG criteria for atrial flutter includes:

1. Classic saw-tooth-patterned flutter waves with dominant negative deflection or rounded or bimodal positive atrial deflections in inferior leads and bimodal negative P waves in lead V1
2. Atrial rate of 240 to 400 beats per minute

Blood tests should include:

• Complete blood count
• Renal function studies
• Serum electrolytes
• Thyroid function panel

A transesophageal echocardiogram (TEE) should be done to visualize if there is an atrial thrombus. Pulmonary function testing is necessary for individuals with atrial flutter because there is a strong correlation between lung disease and atrial arrhythmias.

Electrophysiology studies with mapping will confirm the flutter mechanism and guide catheter ablation treatment.

Management

Treatment for atrial fibrillation will depend upon the individual’s hemodynamic status. If the individual is unstable, then immediate cardioversion followed by anticoagulant therapy is required. Time permitting, it is best to perform a TEE before the cardioversion if the individual can tolerate it. Individuals undergoing cardioversion should be mildly sedated just before the procedure. A beta blocker such as metoprolol (Toprol®) or calcium channel blocker such as diltiazem (Cardizem®) can help slow the heart rate. These medications can be given IV and started with a bolus dose to quickly control heart rate.

Maintenance medications can be administered for long term rate control such as:

• Beta blockers:
  • Metroprolol (Toprol®)
  • Carvedilol (Coreg®)
  • Calcium channel blockers:
    • Diltiazem (Cardizem®)
    • Verapamil (Calan®)
  • Digoxin (Lanoxin®)
• Amiodarone (Pacerone®)

If cardioversion and medication do not control or convert the atrial fibrillation, then radiofrequency catheter ablation can be done. This is typically done under full sedation.

Heart rate and rhythm control is the first line treatment, even for asymptomatic patients with atrial flutter cardioversion with medication is the safest way to treat atrial arrythmias.

Medications for rate and rhythm control include:

• Antiarrhythmic medications:
  • Flecainide (Tambocor®)
  • Propafenone (Rythmol®)
  • Calcium channel blockers:
    • Diltiazem (Cardizem®)
    • Verapamil (Calan®)
  • Beta blockers:
    • Metroprolol (Toprol®)
    • Carvedilol (Coreg®)

These medications can slow the rate but often do not convert atrial flutter to sinus rhythm. Individuals should be started on anticoagulation medication immediately upon a new atrial flutter diagnosis. For hospitalized individuals, IV heparin should be started. If the arrythmia is long term, then an oral anticoagulant such as a direct-acting oral anticoagulant (DOAC) is usually started (Nesheiwat et al., 2023). Some common DOACs include apixaban (Eliquis®), dabigatran (Pradaxa®), and rivaroxaban (Xarelto®). The oral anticoagulant warfarin (Jantoven®) may be considered for patients with AF and a mechanical heart valve.

The standard for atrial flutter treatment is a radiofrequency catheter ablation, which has up to a 95% success rate (Nesheiwat et al., 2023).

Atrial Flutter and Atrial Fibrillation Nursing Care Plan

Nursing Considerations

Use the nursing process to develop a plan of care for individuals. The nursing assessment (with common findings listed), diagnoses, interventions, expected outcomes, and education for atrial flutter and atrial fibrillation are listed below.

Assessment

Assess signs and symptoms :

• Vital signs
• Heart rate and rhythm
• Respiratory status, tachypnea, dyspnea
• Lab results
• ECG results
• Neurological status
• Hemodynamic status
• Contraindications to anticoagulation therapy
• History of atrial arrythmia
• Family history of cardiac arrythmias
• Previous episodes of atrial fibrillation or atrial flutter
• Thyroid disease
• History of valvular disease

Nursing Diagnosis/Risk For

• Decreased cardiac output related to rapid heart rate as evidenced by (Phelps, 2021a):
  • Abnormal ECG showing atrial fibrillation/flutter
  • Hemodynamically unstable
  • Rapid atrial rate
  • Risk for imbalanced fluid volume related to potential for heart failure as evidenced by (Phelps, 2021b):
    • Shortness of breath
    • Edema
    • Dry cough or frothy sputum
  • Anxiety related to hemodynamic instability as evidenced by (Phelps, 2021c):
    • Newly diagnosed atrial fibrillation/flutter
    • Rapid heart rate
    • Decreased blood pressure
    • Cool clammy skin

Interventions

• Monitor vital signs closely for decline.
• Assess their heart rate and rhythm (tachycardia, bradycardia).
• Assess respiratory status (tachypnea, dyspnea).
• Obtain an ECG and compare with previous results.
• Prepare for cardioversion or cardiac ablative therapy if needed.
• Monitor lab test results and report abnormalities.
• Monitor their neurologic status.
• Monitor for chest pain or pressure.
• Auscultate lungs for crackles, rhonchi, and/or diminished sounds.
• Administer and monitor medications as ordered.
• Prepare sedation if cardioversion is imminent.
• Administer oxygen as ordered.
• Monitor their intake and output.
• Maintain large bore IV access.
• Monitor for edema, dyspnea, and frothy sputum.

Expected Outcomes

• Willing to reduce risk factors such as alcohol consumption, smoking, diabetes
• No evidence of stroke or pulmonary embolism
• Follows medication therapy for antiarrhythmic and anticoagulants
• Remains hemodynamically stable

Individual/Caregiver Education

• Condition, treatment options, and expected outcomes
• Notify healthcare provider or seek immediate medical care for:
  • Chest pain
  • Shortness of breath
  • Change in level of consciousness
  • Edema in lower extremities
  • Activity intolerance
  • Inability to take medications as prescribed
  • Medications and potential adverse effects
  • Importance of medication compliance
  • How to take blood pressure and pulse at home
  • Avoid tobacco, alcohol and caffeine

Content Release Date 

4/1/2022

Content Expiration

12/31/2029

Course Contributor

The content for this course was created by Kathleen Koopmann, RN, BSN, PCCN. Kathleen earned her Associate Degree in nursing in 1987 at Mid-Michigan Community College and her Bachelor of Science in nursing in 2018 from Western Governor’s University. She has training from the North Carolina Statewide Program for Infection Control and Epidemiology through NCDHHS and the University of North Carolina. Kathleen has worked in long-term care, outpatient care, acute care, and nursing education. She has hospital experience in Med-Surg, OR/PACU, Critical Care, Telemetry, and outpatient experience in Occupational Health. Kathleen has experience as a clinical instructor for the LPN program at Susquehanna County Career and Technical Center in Pennsylvania. Most recently, she worked in long-term care as a Staff Development Coordinator and Infection Control Practitioner.

Resources

• American Heart Association. AFib resources for patients. https://www.heart.org/en/health-topics/atrial-fibrillation/afib-resources-for-patients--professionals
• American Heart Association. Other heart rhythm disorders. https://www.heart.org/en/health-topics/arrhythmia/about-arrhythmia/other-heart-rhythm- disorders

References

• Nesheiwat, Z., Goyal, A., Jagtap, M. (2023). Atrial fibrillation. StatPearls Publishing; Jan. https://www.ncbi.nlm.nih.gov/books/NBK526072/
• Phelps, L. L., (2021a) Sparks and Taylor’s nursing diagnosis pocket guide (4th ed., pp. 71-73). Wolters Kluwer.
• Phelps, L. L., (2021b) Sparks and Taylor’s nursing diagnosis pocket guide (4th ed., pp.217- 218). Wolters Kluwer.
• Phelps, L. L., (2021c) Sparks and Taylor’s nursing diagnosis pocket guide (4th ed., pp. 23-25). Wolters Kluwer.
• Rodriguez Ziccardi, M., Goyal, A., Maani, C. (2021). Atrial flutter. StatPearls Publishing; Jan. https://www.ncbi.nlm.nih.gov/books/NBK540985/