Atrial Tachyarrhythmias and Atrial Flutter: the Basics of Diagnostics and Modern Opportunities of Therapy

The article is devoted to the description of all types of atrial tachyarrhythmias, including inappropriate sinus tachycardia, which, as a rule, is not paid enough attention in the domestic literature, sinoatrial node reentrant tachycardia, focal and multifocal atrial tachycardia, atrial flutter, and atrial fibrillation. The electrophysiological mechanisms of development and electrocardiographic criteria for the diagnosis of these cardiac rhythm disturbances are presented. Along with this, the article discusses the modern view of the strategy and tactics of pharmacological cardioversion and preventive therapy in patients with the main types of atrial tachyarrhythmias and atrial flutter. It is noted that the prognosis for inappropriate sinus tachycardia, as a rule, is favorable, and therefore, aim of treatment is to reduce the symptoms, and in their absence medical treatment is not necessary. Much attention is paid to drug and interventional treatment of atrial flutter. It is emphasized that catheter ablation of isthmus-dependent atrial flutter in most cases is preferred over long-term pharmacotherapy. However, in prolonged observation (more than 3 years), nearly 1/3 of patients may develop paroxysmal atrial fibrillation. At the same time, catheter ablation of atypical atrial flutter is, in most cases, substantially less effective. The indications and side effects of catheter ablation of the sinus node are also discussed. The authors provide a critical analysis of traditional approaches to the treatment of atrial tachyarrhythmias and analyze new recommendations for the management of these patients presented in Europe and the USA. Based on these recommendations, clear algorithms for the management of patients with atrial tachyarrhythmias are given. The need to prevent thromboembolic complications in some types of atrial tachyarrhythmias is emphasized.

sinus tachycardia, inappropriate sinus tachycardia, sinoatrial node reentrant tachycardia, focal and multifocal atrial tachycardia, atrial flutter

1. Olshansky B., Sullivan R.M. Inappropriate sinus tachycardia. J Am Coll Cardiol. 2013;61:793-801. doi:10.1016/j.jacc.2012.07.074.

2. European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS) and Sociedad Latinoamericana de Estimulacion Cardiaca y Electrofisiologia (SOLAECE). Europace. 2017;19:465-511. doi:10.1093/europace/euw301.

3. Still A.M., Raatikainen P., Ylitalo A. et al. Prevalence, characteristics and natural course of inappropriate sinus tachycardia. Europace. 2005;7:104-12. doi:10.1016/j.eupc.2004.12.007.

4. Sette A., Martino A., Lioy E. et al. Efficacy of ivabradine in a case of inappropriate sinus tachycardia and ventricular dysfunction. J Cardiovasc Electrophysiol. 2010;21:815-7. doi:10.1111/j.1540-8167.2009.01699.x.

5. 2015 ACC/AHA/HRS guidelines for the management adult patients with supraventricular tachycardia. Circulation. 2015;133:e506-74. doi:10.1161/CIR.0000000000000311.

6. Cappato R., Castelvecchio S., Ricci C. et al. Clinical efficacy of ivabradine in patients with inappropriate sinus tachycardia: a prospective, randomized, placebo-controlled doubleblind crossover evaluation. J Am Coll Cardiol. 2012;60:1323-9. doi:10.1016/j.jacc.2012.06.031.

7. Ptaszynski P., Kaczmarek K., Ruta J. et al. Metoprolol succinate vs ivabradine in the treatment of inappropriate sinus tachycardia in patients unresponsive to previous pharmacological therapy. Europace. 2013;15:116-21. doi:10.1093/europace/eus204.

8. Fox K., Ford J., Sted P.G. et al. Ivabradine in stable coronary artery disease without clinical heart failure. N Engl J Med. 2014;371:1091-9. doi:10.1056/NEJMoa1406430.

9. Frankel D.S., Lin D., Anastasio N. et al. Frecuent additional tachyarrhythmias in patients with inappropriate sinus tachycardia undergoing sinus node modification: an important cause of symptom recurrence. J Cardiovasc Electrophysiol. 2012;23:835-9. doi:10.1111/j.1540-8167.2012.02297.x.

10. Saoudi N., Cosio F., Waldo A. et al. A classification of atrial flutter and regular atrial tachycardia according to electrophysiological mechanisms and anatomical bases. Eur Heart J. 2001;22:1162-82. doi:10.1053/euhj.2001.2658.

11. Yusuf S., Camm A.J. Sinus tachyarrhythmias and specific bradycardic agents: a marriage made in heaven? Cardiovasc Pharmacol Ther. 2003;8:89-105. doi:10.1177/107424840300800202.

12. Sanders W.E., Sorrentino R.A., Greenfield R.A. et al. Catheter aflation of sinoatrial node reentrant tachycardia. J Am Coll Cardiol. 1994;23:926-34. doi.org/10.1016/0735-1097(94)90639-4.

13. Steinbesk G., Hoffmann E. “True” atrial tachycardia. Eur Heart J. 1998;19(Suppl E):E10-2, E48-9.

14. de Loma-Osorio F., Diaz-Infante E. et al. Spanish catheter ablation registry. 12th official Report. Rev Esp Cardiol (Engl Ed). 2013;66:983-92. doi:10.1016/j.rec.2013.08.002.

15. Walters T.E., Kistler P.M., Kalman J.M. Radiofrequency ablation for atrial tachycardia and atrial flutter. Heart Lung Circ. 2012;21:386-94. doi:10.1016/j.hlc.2012.02.001.

16. Roth A., Elkayam J., Shapira J. et al. Effectiveness of prehospital synchronous direct-current cardioversion for supraventricular tachyarrhythmias causing unstable hemodynamic states. Am J Cardiol. 2003;91:489-91. doi:10.1016/S0002-9149(02)03257-5.

17. Lim S.H., Anantharaman V., Teo W.S., Chan Y.H. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation. 2009;80:523-8. doi:10.1016/j.resuscitation.2009.01.017.

18. Marcowitz S.M., Stein K.M., Mittal S. et al. Differential effects of adenosine on focal and macroreentrant atrial tachycardia. J Cardiovasc Electrophysiol. 1999;10:489-502. doi:10.1111/j.1540-8167.1999.tb00705.x.

19. Heush A., Kramer H.H., Krogmann O.N. et al. Clinical experience with propafenone for cardiac arrhythmias in the young. Eur Heart J. 1994;15:1050-6.

20. Kang K.T., Etheridge S.P., Kantoch M.J. et al. Current management of focal atrial tachycardia in children: a multicenter experience. Circ Arrhythm Electrophysiol. 2014;7:664-70. doi:10.1161/CIRCEP.113.001423.

21. Roberts-Thomson K.C., Kistler P.M., Haqqani H.M. et al. Focal atrial tachycardias arising from the right atrial appendage: electrocardiographic and electrophysiologic characteristics and radiofrequency ablation. J Cardiovasc Electrophysiol. 2007;18:367-72. doi:10.1111/j.1540- 8167.2006.00754.x.

22. Hazard P.B., Burnett C.R. Treatment of multifocal atrial tachycardia with metoprolol. Crit Care Med. 1987;15:20-5.

23. Reimer A., Paul T., Kallfelz H.C. Efficacy and safety of intravenous and oral propafenone in pediatric cardiac dysrhythmia. Am J Cardiol. 1991;68:741-4. doi:10.1016/0002-9149(91)90646-3.

24. Roberts-Thomson K.C., Kistler P.M., Kalman J.M. Atrial tachycardia: mechanisms, diagnosis and management. Curr Probl Cardiol. 2005;30(10):529-73. doi:10.1016/j.cpcardiol.2005.06.004.

25. Kastor J.A. Arrhythmias. Philadelphia: W.B. Saunders company; 1994.

26. Reithmann C., Hoffmann E., Spitzlberger G. et al. Catheter ablation of atrial flutter due to amiodarone therapy for paroxysmal atrial fibrillation. Eur Heart J. 2000;21:565-72.

27. Satomi K., Chun K.R.J., Tilz R. et al. Catheter ablation of multiple unstable macroreentrant tachycardia within the right atrium free wall in patients without previous cardiac surgery. Circ Arrhythm Electrophysiol. 2010;3:24-31. doi:10.1161/CIRCEP.109.879015.

28. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37:2893-962. doi:10.1093/eurheartj/ehw210.

29. Bastani H., Drea N., Insulander P. et al. Cryothermal vs. radiofrequency ablation as atrial flutter therapy: a randomized comparison. Europace. 2013;15:420-8.doi:10.1093/europace/eus261.

30. Miyazaki S., Shah A.J., Hocini M. et al. Recurrent spontaneous clinical perimitral atrial tachycardia in the context of atrial fibrillation ablation. Heart Phythm. 2015;12:104-10. doi:10.1016/j.hrthm.2014.09.055.

31. Ghali W.A., Wasil B.I., Brant R. et al. Atrial flutter and the risk of thromboembolism: a systematic review and meta-analysis. Am J Med. 2005;118:101-7. doi:10.1016/j.amjmed.2004.06.048.

32. Bunin Yu.A., Fedyakina L.F. Combined prophylactic antiarrhythmic therapy of atrial fibrillation and flutter. Russian Journal of Cardiology. 2006;6:35-45 (In Russ.)