From the Guidelines
Generally, diltiazem should be discontinued after successful radiofrequency ablation for atrial flutter, as the primary purpose of the medication is no longer necessary once the flutter circuit has been eliminated. The decision to stop diltiazem should be made in consultation with the treating cardiologist, typically within 1-3 months post-ablation if the patient remains in normal sinus rhythm, as recommended by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1. Discontinuation is usually done gradually, tapering the dose over 1-2 weeks to avoid rebound tachycardia.
However, some patients may need to continue diltiazem if:
- They have coexisting conditions requiring rate control (e.g., atrial fibrillation)
- There's incomplete ablation or recurrence of flutter
- They have hypertension for which diltiazem was also being used The rationale for stopping diltiazem after successful ablation is supported by the guideline's recommendation for ongoing management with antithrombotic therapy, but not specifically for continued use of diltiazem or other rate-controlling medications after ablation 1.
Patients should monitor for any recurrence of symptoms and follow up with their cardiologist as scheduled for post-ablation care and ECG monitoring. It is essential to weigh the potential benefits of discontinuing diltiazem against the risks of recurrence or other complications, considering the individual patient's condition and medical history, as suggested by the guideline's recommendations for catheter ablation and antiarrhythmic therapy 1.
From the Research
Management of Diltiazem after Radiofrequency Ablation for Atrial Flutter
- The decision to continue Diltiazem after radiofrequency ablation for atrial flutter is not directly addressed in the provided studies 2, 3, 4, 5, 6.
- However, the studies suggest that radiofrequency ablation of atrial flutter can be an effective treatment for the condition, with a significant reduction in the recurrence of atrial flutter 2, 4.
- Nevertheless, the studies also indicate that atrial fibrillation is a common occurrence after ablation of atrial flutter, with a reported incidence of up to 50% in some cases 3, 5.
- The use of antiarrhythmic drugs, including Diltiazem, may be continued or initiated after ablation to manage recurrent arrhythmias, including atrial fibrillation 4, 5.
- A survey of electrophysiology centers found that most experts would stop oral anticoagulation after successful cavotricuspid isthmus ablation, even in patients with higher CHADS2-VA2SC scores, but would continue to monitor for recurrent arrhythmias 6.
Factors Influencing the Decision to Continue Diltiazem
- The presence of a history of atrial fibrillation or atypical atrial flutter prior to ablation may influence the decision to continue Diltiazem, as these patients may be at higher risk of recurrent arrhythmias 2, 5.
- The type and severity of underlying heart disease, as well as the presence of other comorbidities, may also impact the decision to continue Diltiazem 4, 5.
- The effectiveness of the ablation procedure and the presence of any complications may also influence the decision to continue Diltiazem 2, 4.