From the Guidelines
The treatment for atrial flutter involves a combination of rate control, rhythm control, and anticoagulation, with catheter ablation being a highly effective long-term management option, especially for symptomatic or refractory cases, as recommended by the 2015 ACC/AHA/HRS guideline 1.
Initial Management
The initial management of atrial flutter typically includes medications to slow the heart rate, such as:
- Beta-blockers (e.g., metoprolol 25-100mg twice daily)
- Calcium channel blockers (e.g., diltiazem 120-360mg daily)
Rhythm Control
For rhythm control, antiarrhythmic drugs such as:
- Flecainide (50-150mg twice daily)
- Propafenone (150-300mg three times daily)
- Amiodarone (loading dose of 600-800mg daily for 1-2 weeks, then 200mg daily) may be used, as suggested by the guideline 1.
Long-term Management
For long-term management, catheter ablation is highly effective, with success rates of 90-95% for typical flutter, and is recommended for patients with symptomatic or refractory atrial flutter 1. Anticoagulation with warfarin (target INR 2-3) or direct oral anticoagulants like apixaban (5mg twice daily) is necessary for patients with risk factors for stroke, as stated in the guideline 1.
Key Considerations
The choice of treatment depends on symptom severity, flutter duration, and patient characteristics. Treatment is essential because untreated flutter can lead to tachycardia-induced cardiomyopathy, heart failure, and increases stroke risk by allowing blood to pool in the atria, forming clots that may embolize, highlighting the importance of prompt and effective management 1.
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.
The treatment for atrial flutter is propafenone (PO), which is indicated to prolong the time to recurrence of paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms. However, concomitant treatment with drugs that increase the functional AV refractory period is recommended to prevent 1:1 conduction and an increase in ventricular rate 2.
- Key points:
- Propafenone (PO) is indicated for paroxysmal atrial fibrillation/flutter (PAF)
- Concomitant treatment with AV refractory period-increasing drugs is recommended
- Flecainide (PO) is not recommended for use in patients with chronic atrial fibrillation, but may be used for paroxysmal atrial fibrillation/flutter (PAF) with caution 3.
From the Research
Treatment for Atrial Flutter
The treatment for atrial flutter typically involves controlling the ventricular rate and converting the arrhythmia to sinus rhythm.
- Diltiazem, a calcium channel blocker, and metoprolol, a beta-blocker, are commonly used to control the ventricular rate in atrial flutter 4.
- A study comparing diltiazem and metoprolol found that diltiazem was more effective in achieving rate control in patients with atrial fibrillation or flutter, with no increased incidence of adverse effects 4.
- Another study found that intravenous beta-blockers and non-dihydropyridine calcium channel blockers are equally effective in rapidly controlling the ventricular rate in atrial fibrillation and flutter 5.
- The choice of treatment may depend on the individual patient's clinical situation, such as the presence of myocardial ischemia, myocardial infarction, or hyperthyroidism 5.
Pharmacologic Cardioversion
Pharmacologic cardioversion is a treatment option for recent-onset atrial fibrillation, which includes atrial flutter.
- A systematic review and Bayesian network meta-analysis found that vernakalant is likely to be the safest option for pharmacologic cardioversion of recent-onset atrial fibrillation 6.
- Flecainide was found to be the most effective option for conversion to sinus rhythm within 4 hours, while ranolazine-amiodarone IV was the most effective option for conversion within 24 hours 6.
- Other studies have found that flecainide-metoprolol combination therapy can improve effectiveness of rhythm control in persistent symptomatic atrial fibrillation and increase tolerability 7.
- Intravenous diltiazem has been shown to be superior to intravenous digoxin in the emergency control of ventricular rate in acute atrial fibrillation and flutter 8.