62 yo woman with palpitations

A 62 yo woman presents to the emergency department with palpitations. She has a past medical history of hypertension.
Her examination is normal.
Vitals on arrival are: Afebrile, heart rate 70bpm, BP 90/42
An ecg is done and is shown below.
​What is the diagnosis?

This is atrial flutter. It is the second most common tachy-arrhythmia after atrial fibrillation
It is a macroreentrant atrial tachycardia with the loop above the AV node in the right atrium.

• type 1 flutter is the most frequent.
  • In this type of flutter, right atrial activation rotates in a counterclockwise direction. 

It usually produces a narrow complex tachycardia, with a classic sawtooth pattern best seen in lead II.
It can conduct as

• 1:1, which can be unstable
• 2:1, which is the most common
• 3:1
• 4:1
• It can also be variable which gives the appearance of an irregular rhythm.

How do we best manage the STABLE patient?
How to best manage the UNSTABLE patient?
​Who would you anticoagulate?
Remember that this arrhythmia will typically not revert with vagal manoeuvres.

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