Anticoagulate Maintain INR >2.0 for 3 — consecutive wk

Cardiovert** and continue anticoagulation

Chronic AF and atrial flutter

Paroxysmal AF ^^ and atrial flutter associated with structural heart disease

Perform transesophageal echocardiogram Cardiovert** If no atrial gg^ and continue thrombus anticoagulation

Chronic anticoagulation

Chronic anticoagulation

Aspirin or no anticoagulation —consider Coumadin in selected patients

Assumes that there are no contraindications to anticoagulation. ' Continue warfarin at least 3 wk - if patient is at high risk of arrhythmia recurrence consider long-term anticoagulation

Fig. 1. Anticoagulation Algorithm.

atrial transport function can be significantly impaired during atrial flutter. Secondly, intracardiac electrograms taken during atrial flutter have demonstrated that although certain areas of the atria demonstrate clear flutter waves—and this is the dominant arrhythmia seen on a surface 12-lead electrocardiogram (ECG)—other areas of the atrium may demonstrate simultaneous fibrillatory activity. Thirdly, patients who have documented atrial flutter at office visits may also have unrecognized AF at other times. One study (16) demonstrated a 5% incidence of intracardiac thrombi and a 20% incidence of spontaneous echo contrast (a risk factor for thromboembolism) in patients with atrial flutter. Another study (17) of unanticoagulated patients undergoing transesophageal echocardiograms had an 11% incidence of left atrial thrombus. Additionally, after cardioversion was performed, 28% of the patients had absence of atrial transport function. In a study of 191 patients with atrial flutter followed for a mean of approx 2 yr, the incidence of thromboembolism was 7% (18). Therefore, the surface electrocardiogram may not be a reliable indicator of intracardiac electrophysiology. The American College of Chest Physicians (AACP) has suggested that atrial flutter should be treated in the same fashion as AF with regards to anticoagulation (19).

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