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Atrial flutter

35 yo M, previously in good health. Cholesterol OK (170s) and bp 120s/70s.  My father and his mother developed high bp in late 50s. No other history of heart trouble. I've recently developed heart rhythm probs.

For last 2 months, I've had episodes when my HR races upon mild exertion. 1st visit to cardiologist occurred the same day as I was having symptoms. The EKG in office was normal.  But a stress test showed  HR quickly at 200. The doctor diagnosed SVT/atrial flutter and put me on 50mg Troprol and 325mg aspirin.

I've had progressively longer episodes during which HR might race. During these, my resting HR is 90s and upon mild exertion HR rises to 180s. Sitting down or just standing still causes the HR to fall back to  resting rate. High HR lasts only for a short time.

The alternative “mode” for heart is normal. The resting HR is 65-75. During extended moderate exertion, HR rises to 110s. Further visits to the cardiologist occurred during this mode and my EKGs were normal.

I had catheter ablation last week. Doctor found three irregular rhythms:1 main & 2 extra. The rhythms switched irregularly between the three. The two extra rhythms were short-lived and came from the left atrium. Despite this, main rhythm was treated but  other 2 were not (too short lived).

Two days after procedure, heart switched over to the "fast" mode and it has been there since then.

Doc wants to wait and see what happens. While this is somewhat unsatisfactory, I understand the need to get a better handle on how often my symptoms occur, their nature, whether medication might help.

1)Is the Toprol worthwhile? I don't feel it is making much difference.
2)My doctor described my condition as unusual for someone of my age. How unusual?
3)What are the major risks? Doc described my condition as not  life-threatening and my biggest risk being an increased chance of stroke, but still very low. I'm a little paranoid about the risk of stroke now.
4)Is a second attempt at ablation worthwhile?
4 Responses
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Avatar universal
I was just reading the above comment when I noticed that I have very similar problems. I was having periods of tachycardia for no apparent reason, then when I mildly exert myself it just jumps up to 180-200bpm.  My cardiologist put me on a beta-blocker.  Then my cardiologist stated everything was very normal, but he was conducting all my testing while I was taking 25mg of Toprol.  Then when I weaned myself down to 12.5mg symptoms started appearing again.  I searched through the Web and found inappropriate sinus tachycardia syndrome, which sounds like it could be it, but even if it is while I ever just be normal again?  All my labs are fine, but it's scary.  I'm unable to do too much in fear that my heart rate will just keep rising if I don't stop what I'm doing. I would like to exercise, but that seems impossible also, what should I do, without increasing or adding more meds?
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230125 tn?1193365857
MEDICAL PROFESSIONAL
It isn't 5/100,000 persons, it is 5/100,000 person-years. It is kind of a funny way to report it.
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Avatar universal
Wow, 5/100,000??
And I had an Atrial Flutter when i was just 19 years old... (cured with ablation)
and yes, I have normal heart...

I wish I were equally "lucky" in everything else. :)
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230125 tn?1193365857
MEDICAL PROFESSIONAL
Hi Zodin,

Atrial flutter is a fast organized rhythm in the atrium that typical beats at a certain rate like 240 beats per minute to 440 beats per minute (or faster).  Let's say your atrail rhythm is beating at 360 beats per minute.  When you are resting and on a beta blocker, one in ever four beats from your atrium is conducted to your ventricle (4:1) response or 360:90 beats in a minute.  When you exert yourself, are under stress, over caffeinated, etc, you can switch from every 4th beat conducted to every 3rd or second......that is why your heart rate almost exactly doubles with exertion.

I assume you had an echocardiogram that showed a structurally normal heart.

If you want to read a medical article on predictors of atrial flutter, check out this link:

http://content.onlinejacc.org/cgi/content/full/36/7/2242

This link has an EKG with atrial flutter and 4:1 conduction (atrial beats are the smaller deflections and ventricular beats are the larger deflection).

1) Is the Toprol worthwhile? I don't feel it is making much difference.

It is worth while because it probably keeps your heart rate slower at greater degrees of exertion than if you weren’t taking it.  If you don’t like beta blockers, calcium channel blockers like diltiazem and verapamil are equally effect.

2) My doctor described my condition as unusual for someone of my age. How unusual?

We see people like yourself everyday, but our job is heart rhythm problems so I have a referral bias.  In the general population for someone your age, this is not a common problem.  The number is 5/100,000 person years for those less than 50 years old.

3)What are the major risks? Doc described my condition as not life-threatening and my biggest risk being an increased chance of stroke, but still very low. I'm a little paranoid about the risk of stroke now.

The risk factors for stroke are hypertension, diabetes, age greather tha 65, heart failure and previous stroke or TIA.  You don’t have any of these risk factors.  Your risk of stroke is very low.  

You also do not have the typical risk factors for atrial flutter: being male, heart failure, lung disease, hypertension.


4)Is a second attempt at ablation worthwhile?

The reason your doctor wants to wait is to see if the healing scar prevents future recurrence.  If you have atrial fibrillation as well, it gets a little more complicated.  It depends on if the left atrial heart rhythms were atrial fibrillation or atrial flutter.  It would be important to see if you have atrial fibrillation that triggers your atrial flutter.  If this is case, you may need a different type of ablation involving the left atrium.  People with atrial fibrillation and atrial flutter usually need an atrial fibrillation ablation (pulmonary vein isolation -- PVI) if they have symptomatic arrhythmias that are refractory to anti arrhythmic medicines like flecainide or propafenone.  This can be done because a PVI is anatomically based.  If the left sided rhythm is atrial flutter, you need to be in left atrial flutter to map the arrhythmia and ablate it.

If this is pure atrial flutter, it might worth trying flecainide with a beta blocker or calcium channel blocker while the scar heals from your ablation – this might help keep you out of atrial flutter.

If your heart rhythm causes symptoms and you keep having atrial flutter, it is probably worth a repeat procedure.  If you have both atrial fib and atrial flutter AND atrial flutter is the predominant rhythm, you should know that you have an increased chance of developing more atrial fibrillation later in life.  A repeat atrial flutter ablation may buy you some time between now and if atrial fibrillation becomes an issue.  This may require another ablation if symptomatic and refractory to medications.  Every year we get better at treating atrial fibrillation.

This is a lot to digest.  I hope I explained it clearly enough for you.

Thanks for posting and good luck.  
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