From the Guidelines
The treatment of atrial flutter involves a combination of rate control, rhythm control, and anticoagulation, with initial management focusing on controlling the ventricular rate using medications such as beta-blockers or calcium channel blockers, and rhythm control achieved through electrical cardioversion or pharmacological cardioversion with antiarrhythmic drugs like amiodarone or ibutilide, as recommended by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1.
Key Recommendations
- For acute pharmacological cardioversion, oral dofetilide or intravenous ibutilide is useful in patients with atrial flutter, with a conversion rate of approximately 60% for ibutilide 1.
- For acute rate control, intravenous or oral beta blockers, diltiazem, or verapamil are useful in patients with atrial flutter who are hemodynamically stable, with the goal of achieving a ventricular rate of less than 100 beats per minute 1.
- Elective synchronized cardioversion is indicated in stable patients with well-tolerated atrial flutter when a rhythm-control strategy is being pursued, with a success rate of approximately 90% 1.
- Anticoagulation is essential to prevent thromboembolism, typically with warfarin or direct oral anticoagulants like apixaban, rivaroxaban, or dabigatran, with the choice of anticoagulant depending on the patient's stroke risk and bleeding risk 1.
Long-term Management
- Catheter ablation targeting the cavotricuspid isthmus is highly effective for long-term management of atrial flutter, with success rates exceeding 90%, and is particularly beneficial for patients with recurrent episodes despite medication or those who cannot tolerate antiarrhythmic drugs 1.
- The choice of treatment should be individualized based on the patient's symptoms, underlying heart disease, and comorbidities, with consideration of the potential risks and benefits of each treatment option 1.
From the FDA Drug Label
Ibutilide fumarate injection produces dose-related prolongation of the QT interval, which is thought to be associated with its antiarrhythmic activity. Among patients with atrial flutter, 53% receiving 1 mg ibutilide fumarate and 70% receiving 2 mg ibutilide fumarate converted, compared to 18% of those receiving sotalol Conversion of atrial flutter/ fibrillation usually (70% of those who converted) occurred within 30 minutes of the start of infusion and was dose related.
Treatment of Atrial Flutter with Ibutilide:
- Ibutilide fumarate injection is effective in converting atrial flutter to normal sinus rhythm.
- The conversion rate is dose-related, with higher doses resulting in higher conversion rates.
- In clinical trials, 53% of patients with atrial flutter converted with a 1 mg dose of ibutilide fumarate, and 70% converted with a 2 mg dose.
- Conversion usually occurs within 30 minutes of the start of infusion. 2
From the Research
Treatment Options for Atrial Flutter
- Electrical cardioversion and/or antiarrhythmic medications are commonly used to treat atrial flutter 3
- Type I and Type III antiarrhythmic drugs can be used to terminate or prevent recurrent episodes of atrial flutter, while Type II (beta-blockers) and Type IV (calcium channel blockers) can be used to control the ventricular rate 3
- Radiofrequency catheter ablation is a highly effective treatment option for atrial flutter, with a success rate of over 90% 3
Ventricular Rate Control in Atrial Flutter
- Atrioventricular node blocking agents, such as beta-adrenergic blockers, non-dihydropyridine calcium channel blockers, and digoxin, can be used to control ventricular rate in atrial flutter 4
- Intravenous beta-blockers and non-dihydropyridine calcium channel blockers are equally effective in rapidly controlling ventricular rate 4
- Diltiazem (a calcium channel blocker) has been shown to be more effective than metoprolol (a beta-blocker) in achieving rate control in patients with atrial fibrillation or flutter 5
Pharmacological and Electrical Cardioversion
- A network meta-analysis found that various antiarrhythmic drugs, including ibutilide, propafenone, and amiodarone, can be effective in converting atrial flutter to sinus rhythm 6
- Electrical cardioversion is also a highly effective treatment option for atrial flutter, with a success rate of over 97% 6
- The choice of cardioversion method depends on various factors, including patient comorbidity profile, antiarrhythmic drug onset of action and side effect profile, and the need for sedation or anesthesia support 6
Interaction between Calcium Channel Blockers and Ibutilide
- Calcium channel blockers do not appear to have an antagonistic effect on the efficacy of ibutilide in converting atrial fibrillation or flutter to sinus rhythm 7
- A retrospective analysis found no differences in conversion rates or ECG effects between patients taking and not taking calcium channel blockers 7