From the Guidelines
Atrial flutter management should prioritize catheter ablation of the cavotricuspid isthmus (CTI) for symptomatic or refractory cases, as it is highly effective with success rates exceeding 90% 1.
Key Recommendations
- Rate control can be achieved with beta-blockers, diltiazem, or verapamil, with beta blockers being generally preferred in patients with heart failure 1.
- Rhythm control options include electrical cardioversion, pharmacological cardioversion with amiodarone, flecainide, or propafenone, and catheter ablation.
- Catheter ablation is recommended for typical flutter, with success rates exceeding 90% 1.
- Anticoagulation follows the same guidelines as atrial fibrillation, using CHA₂DS₂-VASc score, with options including warfarin or direct oral anticoagulants like apixaban, rivaroxaban, dabigatran, or edoxaban 1.
Treatment Approach
- Initial management includes rate control and assessment for rhythm control.
- Catheter ablation should be considered for symptomatic or refractory cases 1.
- Pharmacological cardioversion options should be tailored to the patient's underlying heart disease and comorbidities.
- Anticoagulation should be considered in all patients with atrial flutter, with the intensity of anticoagulation determined by the CHA₂DS₂-VASc score 1.
Important Considerations
- The risk of stroke in patients with atrial flutter is mitigated by anticoagulation 1.
- Catheter ablation may be reasonable for asymptomatic patients with recurrent atrial flutter, after carefully weighing potential risks and benefits 1.
- Flecainide or propafenone may be considered to maintain sinus rhythm in patients without structural heart disease or ischemic heart disease who have symptomatic recurrent atrial flutter, but with caution due to the risk of 1:1 conduction 1.
From the FDA Drug Label
Sotalol AF are indicated for the maintenance of normal sinus rhythm [delay in time to recurrence of atrial fibrillation/atrial flutter (AFIB/AFL)] in patients with symptomatic AFIB/AFL who are currently in sinus rhythm. In patients without structural heart disease, propafenone is indicated to prolong the time to recurrence of – paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms.
Atrial Flutter Management Guidelines:
- Sotalol is indicated for the maintenance of normal sinus rhythm in patients with symptomatic atrial fibrillation/atrial flutter (AFIB/AFL) who are currently in sinus rhythm 2.
- Propafenone is indicated to prolong the time to recurrence of paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms in patients without structural heart disease 3.
- Key Considerations:
- Sotalol should be reserved for patients with highly symptomatic AFIB/AFL.
- Propafenone should not be used to control ventricular rate during atrial fibrillation.
- Concomitant treatment with drugs that increase the functional AV refractory period is recommended when using propafenone to treat atrial flutter.
From the Research
Atrial Flutter Management Guidelines
- Atrial flutter is a macroreentrant arrhythmia that is associated with cardiovascular and pulmonary disease, with 200,000 new cases expected to develop every year in the United States 4.
- The most common form of atrial flutter involves a large reentrant circuit within the right atrium, encircling the tricuspid annulus, and treatment often involves electrical cardioversion and/or antiarrhythmic medications 4.
- Type I and Type III antiarrhythmic drugs are often used to terminate or prevent recurrent episodes, while Type II (beta-blockers) and Type IV (calcium channel blockers) can be used to control the ventricular rate during atrial flutter 4.
- Radiofrequency catheter ablation has been used to interrupt the reentrant circuit and prevent recurrences of atrial flutter, with an acute success rate of over 90% 4.
Ventricular Rate Control
- Atrioventricular node blocking agents, including beta-adrenergic blockers, non-dihydropyridine calcium channel blockers, and digoxin, are usually effective in controlling ventricular rate in atrial fibrillation and flutter 5.
- Intravenous beta-blockers and non-dihydropyridine calcium channel blockers are equally effective in rapidly controlling the ventricular rate, while the addition of digoxin to the regimen causes a favorable outcome 5.
- Diltiazem (calcium channel blocker) and metoprolol (beta-blocker) are both commonly used to treat atrial fibrillation/flutter, with diltiazem being more effective in achieving rate control in ED patients with AFF 6.
Treatment Strategies
- The four major concerns that must be addressed in the treatment of atrial flutter are reversion to normal sinus rhythm, maintenance of normal sinus rhythm, control of the ventricular rate, and prevention of systemic embolization 7.
- Management strategies may be formed based on the evaluation of the entire clinical context, including cardiovascular status and associated noncardiac clinical disorders 8.
- When clinical condition is unstable or hemodynamically compromised, immediate electrical cardioversion is the treatment of choice, as the best measure to control ventricular rate is by conversion to sinus rhythm 5, 8.