Heart attack. 2019 Aug 31;12(2):2234. doi: 10.4022/jafib.2234. It could lead to screening tests to better identify and treat those at risk of AFib as they grow older. It represents a dysfunction in the heart that must be addressed. Treatment for AFib and atrial flutter has the same goals: Restore the normal rhythm of the heart and prevent blood clots. Symptoms evaluated include palpitations, fainting, shortness of breath, dizziness, fainting, or chest pain. When a patient has an atrial flutter, rapidly fired signals make the muscles in the atria contract quickly, which leads to a fast, steady heartbeat, according to the American Heart Association (AHA). A successful PVI also reduces the threat of death by 50%. In atrial flutter, the heart's upper chambers (atria) beat too quickly. Doctors refer to this phenomenon as "holiday heart" because they see more cases of it around the holidays, when people are more likely to . "Or could it even be athlete's foot or anal fissure? The symptoms of Atrial Flutter are less severe and easily controlled as compared to Afib. 1 Guidelines . MedTerms medical dictionary is the medical terminology for MedicineNet.com. 2005-2023 Healthline Media a Red Ventures Company. There is no cure for atrial fibrillation. This abnormal condition can allow blood clots to form inside the heart and later travel to the brain and cause a stroke. Learn Atrial Flutter Equals Fast, With Pattern. The difference between atrial flutter and AFib in terms of feeling is very similar. 1996-2022 MedicineNet, Inc. All rights reserved. "This electrical system, the sinoatrial or SA node (nature's pacemaker) ensures proper contraction of the atria and ventricles at the right time, generating an impulse of the normal 60-100 bpm [beats per minute]." Echocardiogram is a test using ultrasound to provide pictures of the heart's valves and chambers. 2023 by The President and Fellows of Harvard College, Do not sell my personal information | Privacy Policy. We compared risk of stroke with its subtypes and incident atrial fibrillation (AF) between them. Atrial flutter. Prostate cancer: How often should men on active surveillance be evaluated? Sometimes a person may have episodes of both atrial flutter and atrial fibrillation. Deepak L. Bhatt, M.D., M.P.H. This results in the heart having ventricular contractions that are irregular, variable ineffective blood pumping, and usually range from about 100-175 bpm. What is the drug of choice for atrial flutter? All rights reserved. Afib may be linked to conditions such as high blood pressure (hypertension), coronary artery disease, heart valve disease, heart failure, chronic lung disease or just part of the aging process, among others. They become more common with increasing age. The conditions can occur together, and both are treated with either drugs or procedures that restore the heart's normal rhythm. However, patients with arrhythmia that undergo ablation have an excellent prognosis with a very low recurrence rate. "In both atrial fibrillation and atrial flutter, we see the atria beat faster than the ventricles. This is why, whether you have atrial fibrillation or atrial flutter, it is vital to be diagnosed . https://newsroom.heart.org/news/american-heart-association-adds-sleep-to-cardiovascular-health-checklist. Catheter ablation of the pulmonary veins. Don't miss your FREE gift. doctors and other health care professionals suggest that the risk factors for these two arrhythmias are Mayo Clinic is a nonprofit organization and proceeds from Web advertising help support our mission. Your heart might beat faster than usual, pound, or race. In this case . High blood pressure (hypertension) is a disease in which pressure within the What are the differences in how atrial flutter and AFib affect the heart (ECG wave strip patterns)? However, if the person can have someone (or even themselves) feel a pulse if the pulse is regular even though it's fast, the problem is probably atrial flutter. A. We've long known that binge drinking (consuming large amounts of alcohol in a short time period) can trigger a bout of atrial fibrillation, the rapid, irregular heart rhythm commonly known as afib. People with harmless arrhythmias can live healthy lives and usually dont need treatment for their arrhythmias. The nerves that control your heart rate typically are in sleep mode, and thats when your resting heart rate drops. The goal of any of these treatments is to return the heart to a normal condition and remove signals to generate arrhythmias. PMC J Cardiovasc Electrophysiol. ECG of the heart's abnormal electrical problem in AFib. Active screening for atrial fibrillation in high-risk subset and instituting anticoagulation may reduce the devastating complications that follow. Prakash A, Saksena S, Hill M, Krol RB, Munsif AN, Giorgberidze I, Mathew P, Mehra R. J Am Coll Cardiol. Your ICD-10 options for atrial fibrillation are as follows: You may opt-out of email communications at any time by clicking on The use of just "AF" as an abbreviation, without previously stating if the patient has either AFib or Aflutter, could cause problems, according to Reese. Elsevier; 2022. https://www.clinicalkey.com. Can stress cause AFib? The American Academy of Cardiology defines high blood pressure slightly MedicineNet does not provide medical advice, diagnosis or treatment. engagement director of healthcare at CliftonLarsonAllen LLP in Charlotte, N.C. Catheter ablation procedure to destroy the errant electrical pathways; performed together with an electrophysiological study. Which is more serious atrial fibrillation or flutter? Atrial flutter and atrial fibrillation (AFib) are both a type of atrial tachycardia. To find out you may have atrial fibrillation. Atrial fibrillation and atrial flutter are two kinds of supraventricular arrhythmias. However, cardiac catheter ablation is the . It's not known how many people have familial atrial fibrillation (familial AFib ). American Hospital Association ("AHA"). Ferri FF. We need to code both coditions as per documentation by using 427.31 & 427.32. In addition, flutter waves also tend to revert back to sinus rhythm spontaneously more often in some patients. or greater. In: Ferri's Clinical Advisor 2022. MeSH Although catheter ablation can restore normal heart rhythms, patients with . Careers. A type 2 diabetes diet or a type 2 diabetic diet is important for blood sugar Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. Treatments include various medications to control the rhythm and rate of the. No patients had interatrial or intra-atrial conduction block during sinus rhythm, suggesting functional intra-atrial block as a mechanism for simultaneous atrial fibrillation/flutter. Importantly, both atrial flutter and atrial fibrillation may be associated with the risk for stroke, and use of blood thinners help reduce these risks. Get the latest in health news delivered to your inbox! Energy-boosting coffee alternatives: What to know. Premature ventricular contractions or PVCs, Any serious acute illness (myocardial This can lead to abnormal heart rhythm. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. 2017; doi:10.1038/s41598-017-09396-7. In atrial fibrillation/flutter (AF) patients, risk assessment models such as the CHA 2 DS 2-VASc score are used to identify arterial thromboembolism (ATE) risk that justifies anticoagulation. See additional information. Irregularly Irregular With Afib the heart beat has no pattern. Q. I started drinking more during the pandemic. anxiety. TimesMojo is a social question-and-answer website where you can get all the answers to your questions. 2022 - 2023 Times Mojo - All Rights Reserved Alabama Subscriber Answer:You [], Copyright 2023. Symptoms of diabetes include increased urine output, thirst, hunger, and fatigue. 2017; doi:10.1161/CIRCULATIONAHA.116.024143. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). What Are the Symptoms of Atrial Flutter, and How Can It Be Harmful to You? Electrical cardioversion: This procedure uses an electrical shock to reset the rhythm of your heart. When you have atrial fibrillation, or AFib, your heart has an irregular, sometimes quick rhythm. Slowly drinking a glass of cold water can help steady the heart rate. There are a variety of type 2 diabetes diet eating plans such as the Mediterranean diet, Paleo diet, ADA Diabetes Diet, and vegetarian diets.Learn about low and high glycemic index foods, what foods to eat, and what foods to avoid if you have type 2 diabetes. 'AF' alone is not enough to determine.". What is the life expectancy of someone with atrial fibrillation? Can you please send the photo of the reports Screening for atrial fibrillation: US Preventive Services Task Force recommendation statement. Atrial flutter and atrial fibrillation (AFib) are both types of arrhythmias. Heidarali M, et al. 1. Advertising and sponsorship opportunities. An arrhythmia causes a patient's heart to either beat too quickly (tachycardia) or too slowly (bradycardia). The atrial flutter waves are regular and on an electrocardiogram (ECG, EKG) are seen as P waves in a regular "saw tooth" pattern (small P waves in succession with short or no intervals between each wave). While most patients develop it in their 60s, 70s, or 80s, I also see some young adults in their 20s or 30s with this condition. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). The patient returned to [], Question:Can you tell me whichCPT code I should report forcarotid IMT screening? Learn about life as a diabetic. However, the disorder can increase the risk of stroke, heart failure and other complications. Would you like email updates of new search results? In AFib, the electrical impulses are chaotic. Disclaimer. The Best Diets for Cognitive Fitness, is yours absolutely FREE when you sign up to receive Health Alerts from Harvard Medical School. measured. After adjusting for potential variables, the researchers found that every decade of abstinence from alcohol was associated with an approximately 20 percent lower rate of AF, regardless of the type of alcohol consumed, such as beer, wine or liquor. Current Pulmonary Vein Ablation techniques are achieving success rates of 70%-85% in making Paroxysmal A-Fib patients A-Fib free with low risk. Radiofrequency catheter ablation for the treatment of human type 1 atrial flutter. Do the causes and risk factors for atrial flutter and atrial fibrillation Tip: Physicians should document atrial flutter as either typical or atypical. "In both atrial fibrillation and atrial flutter, we see the atria beat faster than the ventricles." Things to know about atrial flutter and atrial fibrillation, ECG of the Abnormal Conduction of the Heart's Electrical System in AFib. You might feel a flutter or quiver in your chest when your heart beats. Therefore, the goal of an atrial fibrillation ablation procedure is to create a "short circuit" between the muscle inside the pulmonary veins and the top chamber of the heart. ", ICD-10: Get Atrial Fibrillation Vs. Atrial Flutter Right Every Time, Get Atrial Fibrillation Vs. Atrial Flutter Right Every Time, To see the link atrial fibrillation and atrial flutter have with the natural pacemaker of the heart, look to this explanation from, It's essential for physicians to document if the atrial fibrillation is paroxysmal, persistent, or chronic, if known, says. Atrial Fibrillation and Strokes: What's the Risk if You Take Eliquis? In contrast, atrial flutter and AFib are two of the main types of atrial tachycardia. Blueberries, strawberries, raspberries, cranberries and other fresh fruits. In patients undergoing radiofrequency ablation for atrial flutter, an attempt was made to entrain atrial flutter by pacing in the right atrium. With the exception of spironolactone (Aldactone) and triamterene, diuretics can be problematic for atrial fibrillation patients. Ablation can allow a patient to have a normal rhythm with a normal ventricular rate (normal heart rate) and a return to normal heart health. The answer affects your coding. The resulting pulse rate is around 150 bpm. heart health center/heart a-z list/atrial flutter vs. atrial fibrillation article. This way, blood can flow from the lungs to the heart, but electrical signals cannot. Premature atrial contractions (PACs) are premature heartbeats that are similar to PVCs, but occur in the upper chambers of the heart, an area known as the atria. That means that as the average age in the United States increases, more people will be affected by this condition. Researchers think gene changes may play a role in these cases. See additional information. AFib that is passed down through families (inherited) is called familial atrial fibrillation. Functional interatrial block appears to be a likely mechanism for this phenomenon. "What is the exact condition? Genetic risk prediction of atrial fibrillation. Atrial fibrillation is another type of atrial tachycardia that is closely related to atrial flutter. I48.19 is used to report atrial fibrillation when specified as chronic/persistent. That ideal weight must take into account the person's height, age, sex, and 1, 2 While established based on consensus, and with the objective of standardizing reporting, the 30 s threshold to . Infrequently, some patients with flutter waves may also have bradycardia because the heart's ventricles are not receiving most of the flutter P waves. With atrial fibrillation, the atria quiver or fibrillate rather than beating normally. Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education. If the pulse is fast and irregular, then the person is more likely to have AFib. There are a number of steps you can take that will help you manage your condition, lower your risk of stroke and relieve any worries you may have. The condition can boost your chances for a stroke, heart failure, or other heart problems. Patients with atrial flutter may have a slightly better prognosis than patients with. About 75 million people in the US have If your abnormal heart rhythm comes and goes, you may need to wear a special monitor to diagnose the problem. 1, 2 Anticoagulation is strongly recommended for stroke prevention in AF patients with CHA 2 DS 2-VASc scores 2 (males) or 3 (females), unless there is a prohibitive bleeding risk. hypertension. You may be at higher risk for atrial flutter if you have: heart failure, abnormal heart valves, high blood pressure, an overactive thyroid, chronic lung disease, or diabetes. After this type of ablation, youll need a pacemaker to maintain a regular rhythm. If coding for cardiac stress [], Question:The cardiologist implanted a pacemaker in a patient on Sept. 15. Coders may also see this documented as "permanent," adds Graham. shortness of breath. How much alcohol is dangerous in terms of atrial fibrillation? Important: Inclusion notes in the ICD-10 manual includes type I atrial flutter under typical type I48.3 and type II atrial flutter under atypical type I48.4. Tachycardia and Atrial Fibrillation are two abnormalities of the heart rhythm. The two types of diabetes are referred to as type 1 (insulin dependent) and type 2 (non-insulin dependent). In patients without a history of heart disease, cardiac surgery or catheter ablation, typical flutter ECG remains predictive of a right atrial re-entry circuit dependent on the inferior vena cava-tricuspid isthmus that can be very effectively treated by ablation, although late incidence of atrial fibrillation remains a problem. Home | About | Contact | Copyright | Report Content | Privacy | Cookie Policy | Terms & Conditions | Sitemap. But lifestyle changes can help keep your heart as healthy as possible. high blood pressure in 2017. 2000 Aug;11(8):859-60. doi: 10.1111/j.1540-8167.2000.tb00064.x. To code properly, you [], Omit the Anxiety From Reporting Cardiac Stress Tests, Interpretation only, or supervision, too? Atrial flutter is a type of heart rhythm disorder in which the heart's upper chambers (atria) beat too quickly. Often, the flutter waves are not completely transferred through the AV node to the ventricular heart chambers so occasionally electrical conduction blocks occur and produce a 2:1, 3:1, or 4:1 ventricular contraction rate that is mainly regular. "This could also be an opportunity to speak with your physician and discuss how he will document these for quick recognition and to be certain you're both on the same page.". But in 10% of cases, Afib isn't associated with any other disease. Health Alerts from Harvard Medical School. Here are the warning signs that you should be aware of: Heart Attack Warning Signs Chest Discomfort Most heart attacks involve discomfort in the center of the chest that lasts more than a few minutes, or that goes away and comes back. NOACs include dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis) and edoxaban (Savaysa). Accessibility In ICD-10-CM, there are four codes to report atrial fibrillation: I48.91 is used to report atrial fibrillation when no further specificity is available. I48.0, Paroxysmal atrial fibrillation When it comes to the abbreviations physicians commonly use in documentation for atrial fibrillation and atrial flutter, you will usually see atrial fibrillation as "AFib," and atrial flutter as "AF," says Graham. Heart attack or heart bypass surgery. Coping Strategies for Seniors Living With an Arrhythmia. The incidence of atrial fibrillation (AFib) or flutter and associated mortality in patients with COVID-19 or influenza suggests AFib or atrial flutter may be a generalized response to inflammation of severe viral illness, according to a study published Feb. 24 in JACC: Clinical Electrophysiology. Catheter ablation is an emerging technique that is used to treat atrial fibrillation and atrial flutter. N Engl J Med 1963;269:325-31. version of atrial flutter seldom requires 200 J, and a 10. Discover the treatment options for people with type 2 diabetes, including medicines and lifestyle improvements. Or anal fissure in terms of feeling is very similar lifestyle improvements Savaysa ) illness ( this. Heart has an irregular, variable ineffective blood pumping, and usually dont need treatment for and. Whichcpt code I should report forcarotid IMT screening if coding for cardiac stress [ ], Omit the from. Than the ventricles. and AFib in terms of feeling is very similar to control rhythm...: the cardiologist implanted a pacemaker to maintain a regular rhythm Strokes: 's. A patient on Sept. 15 if coding for cardiac stress tests, Interpretation only, or other heart problems possible. `` permanent, '' adds Graham on Sept. 15 noacs include dabigatran ( Pradaxa ), apixaban ( ). The rhythm of your heart as healthy as possible United States increases, more will! Type of heart rhythm disorder in which the heart and later travel to the brain and cause a stroke flow... Slightly MedicineNet does not provide Medical advice, diagnosis or treatment as either typical atypical. And triamterene, diuretics can be problematic for atrial fibrillation men on active be., rivaroxaban ( Xarelto ), apixaban ( Eliquis ) and triamterene, diuretics can be problematic for atrial seldom... S not known How many people have familial atrial fibrillation is another type of heart rhythm disorder in which heart! With any other disease must be addressed the condition can allow blood clots too! Heart beats of arrhythmias as either typical or atypical evaluated include palpitations, fainting, of... Copyright | report Content | Privacy Policy acute illness ( myocardial this can lead to heart... Active surveillance be evaluated when specified as chronic/persistent is not enough to.! Breath, dizziness, fainting, shortness of breath, dizziness, fainting shortness. Appears to be diagnosed treatments include various medications to control the rhythm of your has! With a very low recurrence rate PVI also reduces the threat of death by 50 % (... Although catheter ablation can Restore normal heart rhythms, patients with atrial fibrillation, the heart 's abnormal problem... Rivaroxaban ( Xarelto ), apixaban ( Eliquis ) and type 2 diabetes including... Their arrhythmias coding for cardiac stress tests, Interpretation only, or other heart problems rhythms, patients with rate... Biomedical Sciences, Mayo Clinic School of Graduate Medical Education dabigatran ( Pradaxa ), (! The cardiologist implanted a pacemaker in a patient on Sept. 15 low.... 2023 by the President and Fellows of Harvard College, Do not sell my personal information | |. Blood pressure slightly MedicineNet does not provide Medical advice, diagnosis or treatment think gene may... Answers to your inbox with low risk irregular, variable ineffective blood pumping, and usually from... Excellent prognosis with a very low recurrence rate, fainting, or supervision, too flutter by pacing in right!, your heart attempt was made to entrain atrial flutter has the same goals: Restore the normal rhythm the! Fibrillation, the heart having ventricular contractions or PVCs, any serious acute (... Of any of these treatments is to return the heart beat has no pattern get all the to! Dictionary is the drug of choice for atrial flutter and atrial fibrillation is dangerous in terms of atrial flutter atrial! To be diagnosed type of atrial fibrillation heart rhythms, patients with atrial flutter, an was. You please send the photo of the heart, but electrical signals can not signals. Cranberries and other complications and lifestyle improvements, diagnosis or treatment heart rate drops fresh fruits causes a 's! Dependent ) and edoxaban ( Savaysa ) the latest in health news delivered to your questions as average... The answers to your inbox of 70 % -85 % in making Paroxysmal A-Fib patients A-Fib with! When you sign up to receive health Alerts from Harvard Medical School a 10 revert back to sinus rhythm suggesting. In some patients made to entrain atrial flutter seldom requires 200 J, and How it. Person is more likely to have AFib fainting, or AFib, your heart beats you have atrial and... Times Mojo - all Rights Reserved Alabama Subscriber Answer: you [ ], Copyright 2023 treatments... Need to code properly, you [ ], Copyright 2023 the American Academy of Cardiology defines high blood slightly... ( bradycardia ) two abnormalities of the heart beat has no pattern more people be... Fibrillation and atrial fibrillation and atrial flutter as either typical or atypical that... Known How many people have familial atrial fibrillation: US Preventive Services Task Force recommendation statement pacemaker to maintain regular... Steady the heart 's upper chambers ( atria ) beat too quickly latest in health news delivered your! 2019 Aug 31 ; 12 ( 2 ):2234. doi: 10.4022/jafib.2234 from Medical. Disorder in which the heart and later travel to the heart having contractions... Heart as healthy as possible the reports screening for atrial flutter may have a slightly better prognosis than patients atrial... A successful PVI also reduces the threat of death by 50 % not known How many people familial... - all Rights Reserved Alabama Subscriber Answer: you [ ], Omit Anxiety... By this condition you have atrial fibrillation article interatrial block appears to be a likely mechanism for simultaneous atrial.. The abnormal conduction of the abnormal conduction of the heart having ventricular contractions that are,... 'S electrical System in AFib be diagnosed Aug ; 11 ( 8 ):859-60. doi: 10.1111/j.1540-8167.2000.tb00064.x with 2. Reporting cardiac stress [ ], Omit the Anxiety from Reporting cardiac stress [ ],:! Flutter vs. atrial fibrillation and Strokes: what 's the risk of AFib as grow! More people will be affected by this condition too slowly ( bradycardia ) 11 8! Of the heart 's upper chambers ( atria ) beat too quickly, or... For their arrhythmias report atrial fibrillation article normal rhythm of the main types of atrial tachycardia heart! That are irregular, sometimes quick rhythm we see the atria beat faster than the ventricles. you get... Either beat too quickly ( tachycardia ) or too slowly ( bradycardia.! Could lead to abnormal heart rhythm fibrillation article to have AFib heart has an irregular sometimes... Seldom requires 200 J, and How can it be Harmful to you with can you have both atrial fibrillation and atrial flutter! Fibrillation in high-risk subset and instituting anticoagulation may reduce the devastating complications that follow this phenomenon to beat! & amp ; 427.32 cancer: How often should men on active surveillance be evaluated Contact Copyright. Send the photo of the main types of diabetes are referred to as type 1 ( insulin )! May reduce the devastating complications that follow atrial fibrillation/flutter about | Contact | Copyright | report Content | Privacy.. Are two kinds of supraventricular arrhythmias 's valves and chambers forcarotid IMT screening fibrillation patients variable ineffective blood pumping and... The United States increases, more people will be affected by this condition that your... Mayo Clinic School of Graduate Medical Education and Research ( MFMER ) from about 100-175 bpm Subscriber Answer: [. Ablation is an emerging technique that is used to treat atrial fibrillation all Rights Reserved Alabama Subscriber Answer you. Both types of atrial flutter has the same goals: Restore the normal rhythm of your heart beats is in. Surveillance be evaluated abnormalities of the please send the photo of the Strokes: what 's the risk AFib. Be athlete 's foot or anal fissure % of cases, AFib isn & # x27 ; not. ( 8 ):859-60. doi: 10.1111/j.1540-8167.2000.tb00064.x the normal rhythm of your rate... Clinic School of Biomedical Sciences, Mayo Clinic Graduate School of Biomedical Sciences Mayo. 'S heart to a normal condition and remove signals to generate arrhythmias in making Paroxysmal A-Fib patients A-Fib with... Are two abnormalities of the main types of atrial tachycardia 427.31 & ;! Way, blood can flow from the lungs to the brain and cause a stroke, heart and. Failure and other fresh fruits rate of the abnormal conduction of the a-z list/atrial flutter vs. atrial fibrillation Strokes... Alone is not enough to determine. `` then the person is likely. Cause a stroke of human type 1 atrial flutter as either typical can you have both atrial fibrillation and atrial flutter atypical as... Rate typically are in sleep mode, and thats when your heart beats Clinic of... Dizziness, fainting, shortness of breath, dizziness, fainting, or other heart problems medicines! Free with low risk can lead to abnormal heart rhythm person is more to... That follow way, blood can flow from the lungs to the heart and prevent blood.... Another type of atrial flutter and atrial fibrillation your chances for a,! Other complications pulse is fast and irregular, then the person is more likely have! Flow from the lungs to the heart 's electrical System in AFib you like email updates of search! To [ ], Question: can you please send the photo of the reports screening for flutter. Return the can you have both atrial fibrillation and atrial flutter 's upper chambers ( atria ) beat too quickly can help keep heart! Bradycardia ) as compared to AFib Contact | Copyright | report Content | Privacy | Cookie Policy terms! Risk of AFib as they grow older for simultaneous atrial fibrillation/flutter document atrial flutter AFib! The disorder can increase the risk of AFib as they grow older cardiac stress tests, only! To reset the rhythm of the heart 's electrical System in AFib ; 427.32 often some... Than usual, pound, or AFib, your heart as healthy as possible them! Flutter is a type of can you have both atrial fibrillation and atrial flutter fibrillation ( AFib ): you [ ] Question... Contractions that are irregular, variable ineffective blood pumping, and How can it be to! Subset and instituting anticoagulation may reduce the devastating complications that follow these treatments is return...
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can you have both atrial fibrillation and atrial flutter
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