A 72-year-old man comes to the emergency department because of palpitations and shortness of breath for the past 24 hours. His medical problems include hypertension, hyperlipidemia, type 2 diabetes mellitus, obstructive sleep apnea, and emphysema. He uses 2 liters of oxygen only during the night. He cannot recall his medications, but uses an unknown daily inhaler for his "lung disease." He quit smoking 12 years ago.
His blood pressure is 132/54 mm Hg and pulse is 155/min. There is faint end expiratory wheezing noted over both lungs. No murmurs are appreciated. There is bilateral 1+ edema in his lower extremities.
An ECG is performed in the emergency department and is shown in this exhibit.
He is admitted to the hospital and started on a diltiazem infusion. The next morning, he continues to have a rapid pulse at 155/min. Transthoracic echocardiogram shows left atrial dilation, normal left ventricular systolic function, and an estimated pulmonary artery systolic pressure of 50 mm Hg.
Which of the following is the best management option for this patient?

Question

A 72-year-old man comes to the emergency department because of palpitations and shortness of breath for the past 24 hours.  His medical problems include hypertension, hyperlipidemia, type 2 diabetes mellitus, obstructive sleep apnea, and emphysema.  He uses 2 liters of oxygen only during the night.  He cannot recall his medications, but uses an unknown daily inhaler for his "lung disease."  He quit smoking 12 years ago.
His blood pressure is 132/54 mm Hg and pulse is 155/min.  There is faint end expiratory wheezing noted over both lungs.  No murmurs are appreciated.  There is bilateral 1+ edema in his lower extremities.
An ECG is performed in the emergency department and is shown in this exhibit. 
He is admitted to the hospital and started on a diltiazem infusion.  The next morning, he continues to have a rapid pulse at 155/min.  Transthoracic echocardiogram shows left atrial dilation, normal left ventricular systolic function, and an estimated pulmonary artery systolic pressure of 50 mm Hg.
Which of the following is the best management option for this patient?

Quizplus · Accepted Answer

This patient's ECG shows typical type I atrial flutter with biphasic "sawtooth" flutter waves (F waves) at a rate of approximately 300/min (arrows). There is 2:1 conduction across the atrioventricular (AV) node with a ventricular rate of about 150/min. Atrial flutter can have a substantial recurrence rate, approaching 50% at 6 months in some studies. flutter waves Radiofrequency (RF) ablation has a much higher success rate and is now generally preferred over long-term antiarrhythmic drugs as the initial therapy to restore and maintain sinus rhythm in patients with typical atrial flutter. The isthmus of tissue between the inferior vena cava and tricuspid annulus (cavotricuspid isthmus) is a necessary component of the macro-reentry circuit in typical type I atrial flutter, and is the anatomic target for radiofrequency ablation. (Choice A) Adenosine is useful for acute termination of AV nodal reentrant tachycardia. However, it has no role in patients with atrial flutter. (Choice B) AV nodal blocking agents (i.e., calcium channel blockers, beta-blockers, or digoxin) are frequently used in patients with atrial flutter or fibrillation with rapid ventricular rates. In contrast to atrial fibrillation, typical atrial flutter is relatively difficult to control with pharmacologic agents. Radiofrequency ablation has emerged as a safe and effective first-line treatment option in such patients. (Choices C and E) Flecainide is a class IC antiarrhythmic agent and is occasionally used to maintain sinus rhythm in patients with paroxysmal atrial fibrillation. Sotalol is a class III antiarrhythmic agent. These drugs have marginal efficacy and a significant side effect profile. They are generally not preferred for restoring or maintaining sinus rhythm in patients with typical atrial flutter. Educational objective: Radiofrequency ablation has an excellent success rate in restoring and maintaining sinus rhythm in patients with typical atrial flutter. It is generally preferred over long-term antiarrhythmic agents as a safe and effective first-line treatment in such patients. __________ References: Diagnosis and management of typical atrial flutter. (http://www.ncbi.nlm.nih.gov/pubmed/19111764) The 1998 NASPE prospective catheter ablation registry. (http://www.ncbi.nlm.nih.gov/pubmed/10879389)

A 72-Year-Old Man Comes to the Emergency Department Because of Palpitations