What medication is used to convert new-onset atrial flutter to sinus rhythm in an inpatient setting?

From the Guidelines

Intravenous ibutilide is the recommended first-line medication for converting new-onset atrial flutter to sinus rhythm in an inpatient setting, given its efficacy and relatively favorable safety profile compared to other options 1. The typical dosing of ibutilide is 1 mg IV over 10 minutes, which can be repeated once after 10 minutes if necessary. It's crucial to ensure the patient is hemodynamically stable and has no contraindications to antiarrhythmic drugs before administration. Some key points to consider when using ibutilide include:

• Ensuring the patient has had anticoagulation if the flutter has been present for more than 48 hours
• Continuous cardiac monitoring during and after administration due to the risk of QT prolongation and torsades de pointes
• Being aware of the potential for hypotension and dyspnea, although these are less common with ibutilide compared to other options like procainamide 1 Alternative options, such as intravenous procainamide, amiodarone, or flecainide, may be considered based on patient-specific factors and the presence of any contraindications to ibutilide 1. However, the choice of medication should always prioritize minimizing morbidity, mortality, and improving quality of life, with ibutilide being the preferred choice based on current evidence 1.

From the FDA Drug Label

Ibutilide fumarate injection is indicated for the rapid conversion of atrial fibrillation or atrial flutter of recent onset to sinus rhythm. The medication used to convert new-onset atrial flutter to sinus rhythm in an inpatient setting is ibutilide (IV) 2.

• Key points:
  • Indicated for rapid conversion of atrial flutter to sinus rhythm
  • Effective for arrhythmias of recent onset
  • Less likely to respond if arrhythmia duration is more than 90 days

From the Research

Medications for Converting Atrial Flutter to Sinus Rhythm

• Ibutilide is a 'pure' class III antiarrhythmic drug that has been shown to successfully convert atrial flutter to sinus rhythm in 33 to 49% of patients in placebo-controlled trials 3.
• The conversion rate with ibutilide is higher for atrial flutter than for atrial fibrillation, with a success rate of 57% in patients who developed atrial flutter after cardiac surgery 3.
• Other medications that have been used to convert atrial flutter to sinus rhythm include:
  • Quinidine: a class Ia antiarrhythmic drug that has been shown to be effective in converting atrial flutter to sinus rhythm 4, 5.
  • Procainamide: a class Ia antiarrhythmic drug that has been shown to be effective in converting atrial flutter to sinus rhythm, although it may be less effective than ibutilide 3, 5.
  • Amiodarone: a class III antiarrhythmic drug that has been shown to be effective in converting atrial flutter to sinus rhythm, with a success rate of 78.4% in one study 6, 7.
  • Sotalol: a class III antiarrhythmic drug that has been shown to be effective in converting atrial flutter to sinus rhythm, although it may be less effective than amiodarone in maintaining sinus rhythm 7.
  • Propafenone: a class Ic antiarrhythmic drug that has been shown to be effective in converting atrial flutter to sinus rhythm, with a success rate of 7.15 in one study 5.
  • Dofetilide: a class III antiarrhythmic drug that has been shown to be effective in converting atrial flutter to sinus rhythm, with a success rate of 6.43 in one study 5.
  • Vernakalant: a class III antiarrhythmic drug that has been shown to be effective in converting atrial flutter to sinus rhythm, with a success rate of 1.18 in one study 5.

Factors Affecting Conversion Rate

• The duration of atrial flutter is an important predictor of the success of conversion to sinus rhythm, with higher success rates for recent-onset atrial flutter 3, 6.
• The presence of underlying heart disease, such as hypertension, ischemic heart disease, or congestive heart failure, may reduce the success rate of conversion to sinus rhythm 6.
• The size of the left atrium may also affect the success rate of conversion to sinus rhythm, with larger left atria being associated with lower success rates 6.