A 57-year-old Caucasian female (CF) was admitted to the hospital with atrial flutter with rapid ventricular response (AFl-RVR). She was treated with diltiazem (Cardizem) IV, Cardizem drip and digoxin and converted to normal sinus rhythm (NSR).Past medical history (PMH)Hypertension (HTN), paroxysmal atrial fluttter (one episode 2 years ago), mild coronary artery diseases (CAD) (30% stenosis of LAD, RCA) diagnosed during left heart catheterization (LHC) 2 years ago, hyperlipidemia (HLP).MedicationsLisinopril, ASA (aspirin), Lipitor (atorvastatin).AllergiesNone. She reports profound weakness and joint pain with beta-blockers.Physical examinationHeart rate (HR) 165 bpm.Cardiovascular system (CVS): Clear S1S2, irregularly irregular rhythm.Chest: CTA (B).Abdomen: Soft, NT, ND, +BS.Extremities: no c/c/e.What happened?The patients converted to NSR, Cardizem drip was stopped and she is currently asymptomatic on oral Cardizem 30 mg po q 6 hr. TTE shows a normal ejection fraction and a moderate left atrial enlargement.Should she receive anticoagulation for paroxysmal atrial flutter?Yes. Patients with paroxysmal atrial fibrillation have a risk of thromboembolic complications probably equivalent to those with permanent atrial fibrillation.The American College of Chest Physicians recommended that anticoagulation be considered for all patients with atrial fibrillation, whether it be chronic or paroxysmal (CCJM, 2000).Anticoagulation with warfarin is recommended for all patients older than 75 years, as well as for patients younger than 75 years who have any of the following risk factors:- Prior TIA, systemic embolus or stroke- Hypertension- Poor left ventricular function- Rheumatic mitral valve disease- Prosthetic heart valvesThis is all correct but our patient has a paroxysmal atrial flutter. Do the same guidelines apply?No prospective randomized studies are available to determine the incidence of thromboembolic complications in atrial flutter and the value of anticoagulant therapy. However, associated abnormalities are often present that favorthromboembolic complications such as valvular disease, hypertension, and heart failure. It is therefore advisable to anticoagulate the atrial flutter patients (Circulation. 2002).What happened next?The patient was discharged home with Cardizem CD 120 mg po qd and Coumadin 5 mg po qd. Her INR was 1.5 at the time of discharge. She will have her INR checked on day 2 and 3 after discharge, and the laboratory will call her PCP to have the Coumadin dose adjusted to achieve INR level between 2 and 3. The patient's PCP was informed.Final diagnosisParoxysmal atrial flutter.What did we learn from this case?Patients with paroxysmal atrial fibrillation/flutter have a risk of thromboembolic complications probably equivalent to those with permanent atrial fibrillation/flutter. The American College of Chest Physicians recommended thatanticoagulation be considered for all patients with atrial fibrillation/flutter, whether it be chronic or paroxysmal.