What is the management of atrial flutter?

From the Guidelines

Flutter management should prioritize catheter ablation of the CTI for symptomatic or refractory atrial flutter, as it is a highly effective treatment with a success rate of 90-95% for typical flutter, as recommended by the 2015 ACC/AHA/HRS guideline 1. The management of atrial flutter involves a comprehensive approach to treating this cardiac arrhythmia.

• Rate control can be achieved with medications such as beta-blockers (metoprolol 25-100mg twice daily), calcium channel blockers (diltiazem 120-360mg daily), or digoxin (0.125-0.25mg daily) 1.
• Anticoagulation is essential to prevent stroke, typically with warfarin (target INR 2-3) or direct oral anticoagulants like apixaban (5mg twice daily), as recommended by the 2016 ESC guidelines 1.
• For rhythm control, cardioversion is often effective, using either electrical (synchronized shock of 50-100 joules) or pharmacological methods (amiodarone 150mg IV over 10 minutes, then 1mg/min for 6 hours) 1.
• Long-term management may include catheter ablation, particularly cavotricuspid isthmus ablation, which has a success rate of 90-95% for typical flutter 1.
• Antiarrhythmic medications like amiodarone (200mg daily) or sotalol (80-160mg twice daily) may be used for recurrent episodes, as recommended by the 2015 ACC/AHA/HRS guideline 1. This approach addresses both immediate symptom relief and long-term prevention of complications, as atrial flutter increases stroke risk and can lead to tachycardia-induced cardiomyopathy if left untreated.
• The choice of treatment should be individualized based on the patient's underlying heart disease, comorbidities, and preferences, as recommended by the 2016 ESC guidelines 1.
• The 2015 ACC/AHA/HRS guideline also recommends ongoing management with antithrombotic therapy in patients with atrial flutter to align with recommended antithrombotic therapy for patients with AF 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. The management of atrial flutter involves the use of sotalol to maintain a normal sinus rhythm and delay the recurrence of atrial fibrillation/atrial flutter.

• Key points:
  • Sotalol is indicated for patients with symptomatic AFIB/AFL who are currently in sinus rhythm.
  • The goal of therapy is to prolong the time in normal sinus rhythm.
  • Recurrence is expected in some patients.
  • Sotalol should be reserved for patients in whom AFIB/AFL is highly symptomatic.
  • Patients with paroxysmal AFIB whose AFIB/AFL is easily reversed should usually not be given Sotalol AF 2

From the Research

Atrial Flutter Management

• Atrial flutter is a macroreentrant arrhythmia associated with cardiovascular and pulmonary disease, with 200,000 new cases expected to develop every year in the United States 3.
• 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 3.
• 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 3.

Treatment Options

• 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% 3.
• Diltiazem (calcium channel blocker) and metoprolol (beta-blocker) are commonly used to treat atrial fibrillation/flutter, with diltiazem being more effective in achieving rate control in ED patients with AFF 4.
• A novel pathway for the management of AF and Afl has been developed, incorporating the key concepts of initial diagnosis and management, with the acronym RACE reflecting the 4 main components: rate control, anticoagulation therapy, cardioversion, and electrophysiology/antiarrhythmic medication 5.

Beta-Blockers and Calcium Channel Blockers

• The efficacy and safety of intravenous beta-blockers in acute atrial fibrillation and flutter depend on beta-1 selectivity, with super-selective beta-1 blockers being superior for target heart rate reduction 6.
• Concomitant parenteral calcium channel blockers and beta blockers can be used to achieve rate control in patients with rapid atrial fibrillation or flutter, with a low incidence of bradycardia 7.
• The choice of specific beta-blocker or calcium channel blocker agent is important, as some agents may be more effective or have a better safety profile than others 4, 6, 7.