From the FDA Drug Label
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. As with other agents, some patients with atrial flutter treated with propafenone have developed 1:1 conduction, producing an increase in ventricular rate. Concomitant treatment with drugs that increase the functional AV refractory period is recommended.
Propafenone is a medication that can be used to treat stable atrial flutter, but it is recommended to use it with caution and consider concomitant treatment with drugs that increase the functional AV refractory period to avoid 1:1 conduction and increased ventricular rate.
- Key points:
- Propafenone is indicated for paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms.
- Concomitant treatment with other drugs is recommended to avoid complications.
- The use of propafenone should be reserved for patients in whom the potential benefits outweigh the risks 1.
FLECAINIDE IS NOT RECOMMENDED FOR USE IN PATIENTS WITH CHRONIC ATRIAL FIBRILLATION. Case reports of ventricular proarrhythmic effects in patients treated with flecainide for atrial fibrillation/flutter have included increased PVCs, VT, ventricular fibrillation (VF), and death
Flecainide is not recommended for use in patients with chronic atrial fibrillation, and its use in patients with atrial flutter should be cautious due to the risk of ventricular proarrhythmic effects 2.
From the Research
The most effective medication for treating stable atrial flutter is diltiazem, a calcium channel blocker, due to its rapid and substantial heart rate reduction with no increased incidence of adverse effects, as shown in the study by 3. When considering treatment options for stable atrial flutter, the primary goal is to control the heart rate and prevent complications such as stroke.
- Rate control medications like beta-blockers (metoprolol 25-100mg twice daily) or calcium channel blockers (diltiazem 120-360mg daily) can help control heart rate.
- For rhythm control, antiarrhythmic drugs such as flecainide (50-150mg twice daily), propafenone (150-300mg three times daily), amiodarone (loading dose followed by 200mg daily), or sotalol (80-160mg twice daily) may be used to convert the rhythm to normal sinus rhythm and maintain it. However, according to the most recent and highest quality study by 4, diltiazem is likely to result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up. Additionally, the study by 5 suggests that the efficacy and safety of intravenous beta-blockers in acute atrial fibrillation and flutter is dependent on beta-1 selectivity, but this does not change the fact that diltiazem is the most effective medication for treating stable atrial flutter. It's also important to note that anticoagulation with warfarin (target INR 2-3) or direct oral anticoagulants like apixaban (5mg twice daily) is typically necessary to prevent stroke, and the choice between rate and rhythm control strategies depends on symptoms, duration of atrial flutter, and patient characteristics. Catheter ablation is often the definitive treatment for typical atrial flutter due to its high success rate, and treatment should be individualized based on patient factors including age, comorbidities, and symptom severity, as mentioned in the study by 6.