From the Guidelines
To convert a patient with atrial flutter and rapid ventricular response back to normal sinus rhythm, synchronized cardioversion is recommended as the most effective treatment, especially for hemodynamically unstable patients, according to the 2015 ACC/AHA/HRS guideline 1. When a patient spontaneously goes into atrial flutter with rapid ventricular response, several maneuvers can be performed to try and convert the patient back into normal sinus rhythm.
Initial Management
- Vagal maneuvers are not explicitly mentioned in the provided guideline as a first-line treatment for atrial flutter with rapid ventricular response.
- For acute rate control in hemodynamically stable patients, intravenous or oral beta blockers, diltiazem, or verapamil can be used 1.
Pharmacological Cardioversion
- Oral dofetilide or intravenous ibutilide can be used for acute pharmacological cardioversion, with ibutilide converting atrial flutter to sinus rhythm in approximately 60% of cases 1.
- However, ibutilide carries the risk of torsades de pointes, especially in patients with reduced left ventricular ejection fraction, and requires continuous ECG monitoring during and after administration 1.
Electrical Cardioversion
- Elective synchronized cardioversion is indicated in stable patients with well-tolerated atrial flutter when a rhythm-control strategy is being pursued, and can be successful at lower energy levels than for atrial fibrillation 1.
- Synchronized cardioversion is recommended for acute treatment of patients with atrial flutter who are hemodynamically unstable and do not respond to pharmacological therapies 1.
Other Options
- Rapid atrial pacing can be useful for acute conversion of atrial flutter in patients with pacing wires in place, such as those with a permanent pacemaker or implantable cardioverter-defibrillator, or for temporary atrial pacing after cardiac surgery 1. Overall, the choice of treatment depends on the patient's hemodynamic stability, underlying heart disease, and other factors, with synchronized cardioversion being a highly effective option for restoring normal sinus rhythm in patients with atrial flutter and rapid ventricular response.
From the FDA Drug Label
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 Among patients with atrial flutter, conversion rates at 1.5 hours were: placebo, 4%; 0.25 mg ibutilide fumarate, 56%; 0.5 mg ibutilide fumarate, 61%; and 1 mg ibutilide fumarate, 78% The majority of patients (53% and 72% in the 0.5 mg and 1 mg dose groups, respectively) converted to sinus rhythm remained in sinus rhythm for 24 hours
Maneuvers to convert atrial flutter with RVR to normal sinus rhythm include:
- Administration of ibutilide fumarate injection, with conversion rates ranging from 53% to 78% in clinical trials 2
- The use of other antiarrhythmic drugs, such as sotalol, although ibutilide fumarate was more effective in clinical trials 2
- Electrical cardioversion, which was allowed 90 minutes after the infusion was complete in clinical trials 2 Key considerations:
- Ibutilide fumarate is more effective in patients with atrial flutter than atrial fibrillation 2
- Patients with more recent onset of arrhythmia had a higher rate of conversion 2
From the Research
Maneuvers to Convert Atrial Flutter with RVR to Normal Sinus Rhythm
The following maneuvers can be performed to try and convert a patient with atrial flutter and rapid ventricular response (RVR) back to normal sinus rhythm:
- Vagal maneuvers: These maneuvers, such as the Valsalva maneuver, can increase vagal tone and slow down the heart rate, potentially converting atrial flutter to sinus rhythm 3
- Digital rectal exam: Although not a traditional method, a digital rectal exam has been shown to convert atrial fibrillation to sinus rhythm in one case report, and may be considered as an additional attempt to convert atrial flutter to sinus rhythm 4
- Pharmacological cardioversion: Various antiarrhythmic drugs, such as ibutilide, propafenone, and dofetilide, have been shown to be effective in converting atrial flutter to sinus rhythm 5
- Electrical cardioversion: This is a rhythm control strategy that can be used to restore normal sinus rhythm, and has been shown to be highly effective in converting atrial flutter to sinus rhythm 5, 6
Predictors of Spontaneous Conversion
Some studies have identified predictors of spontaneous conversion of atrial flutter to sinus rhythm, including:
- Presentation with symptoms of <24-h duration: This has been identified as a predictor of spontaneous conversion in patients with atrial fibrillation, and may also be applicable to atrial flutter 7
- Normal left ventricular systolic function: This has been shown to be more common among patients with spontaneous conversion of atrial fibrillation, and may also be a predictor of spontaneous conversion in atrial flutter 7
Other Considerations
Other considerations when managing atrial flutter with RVR include: