The above ECG is that from a 43 year old man who presented with palpitations and feeling his heart rate remain high for longer than usual after exercising. He is normally very fit and active – he is a keen long distance cyclist and participates in triathlons. He has no traditional cardiovascular risk factors or significant medical history and is not on any regular medication.
There is a known association between endurance sports and the later development of atrial arrhythmias. He does not need oral anticoagulation as his risk of thromboembolism is very low (CHADS2VASc score zero), but his atrial flutter should be treated as completely as possible as he is significantly impaired by the arrhythmia.
The best option would be catheter ablation of the flutter, which is a relatively low risk procedure with a high success rate (>95% cure rate) and can avoid the need for long term medication. As he would like to continue cycling, he is unlikely to be willing to take long term antiarrhythmic medication which could impair his performance. Synchronized DC cardioversion may be considered if the Holter shows persistent atrial flutter, but this would only be a temporary measure and his atrial flutter is likely to recur; thus this would not be the best option.