What is the treatment for atrial flutter?

Treatment for Atrial Flutter

Catheter ablation of the cavotricuspid isthmus (CTI) is the recommended first-line treatment for symptomatic atrial flutter or atrial flutter refractory to pharmacological rate control. 1

Acute Management of Atrial Flutter

Hemodynamically Unstable Patients

• Synchronized electrical cardioversion is recommended immediately for patients with hemodynamic instability 1
  • Usually effective at lower energy levels than for atrial fibrillation (typically <50 joules) 1
  • Does not require sedation in unstable patients

Hemodynamically Stable Patients

1. Rate Control Strategy:

   • First-line: Intravenous or oral beta blockers, diltiazem, or verapamil 1
     • Diltiazem may achieve more rapid rate control than metoprolol (95.8% vs 46.4% reaching target heart rate <100 bpm within 30 minutes) 2
     • Caution: Rate control can be more difficult to achieve in atrial flutter than in atrial fibrillation 1
   • For patients with systolic heart failure when beta blockers are contraindicated or ineffective:
     • Intravenous amiodarone 1

2. Rhythm Control Strategy:

   • Pharmacological cardioversion:
     • Oral dofetilide or intravenous ibutilide (first-line agents) 1
       • Ibutilide has 38-76% efficacy for conversion 1
       • Monitor for QT prolongation and torsades de pointes
   • Electrical cardioversion:
     • Elective synchronized cardioversion when rhythm control is pursued 1
   • Rapid atrial pacing for patients with pacing wires in place 1

3. Anticoagulation:

   • Acute antithrombotic therapy following the same recommendations as for atrial fibrillation 1
   • For flutter >48 hours duration, anticoagulation prior to cardioversion 1

Long-Term Management of Atrial Flutter

First-Line Treatment

• Catheter ablation of the CTI for:
  • Symptomatic atrial flutter 1
  • Flutter refractory to pharmacological rate control 1
  • Success rate >90% with low complication rate (1-2%) 3

Alternative Approaches

1. Rate Control:

   • Beta blockers, diltiazem, or verapamil for hemodynamically tolerated atrial flutter 1
   • Choose based on comorbidities:
     • Beta blockers preferred with ischemic heart disease or hyperthyroidism 4
     • Non-dihydropyridine calcium channel blockers preferred with pulmonary disease 4

2. Rhythm Control with Antiarrhythmic Drugs:

   • For symptomatic recurrent atrial flutter when ablation is not feasible:
     • Amiodarone, dofetilide, or sotalol based on underlying heart disease 1
     • Flecainide or propafenone may be considered in patients without structural heart disease 1
   • Sotalol is specifically FDA-approved for maintenance of sinus rhythm in symptomatic atrial flutter 5

3. Anticoagulation:

   • Long-term management with antithrombotic therapy following the same recommendations as for atrial fibrillation 1
   • Use CHADS-VASc score to guide therapy 1

Special Considerations

• Atrial Flutter with Coexisting Atrial Fibrillation:

  • Common association (>50% of cases) 3
  • 22-50% of patients develop atrial fibrillation within 14-30 months after CTI ablation 1
  • Consider CTI ablation in patients undergoing catheter ablation for AF who have a history of atrial flutter 1

• Post-Operative Atrial Flutter:

  • Common in approximately 60% of cases as part of acute disease processes 1
  • Treat underlying condition while managing the arrhythmia

• Pre-excitation Syndrome (WPW):

  • Avoid AV nodal blocking agents (beta blockers, calcium channel blockers, digoxin) 4
  • These can lead to preferential conduction through accessory pathway and precipitate ventricular fibrillation

Pitfalls to Avoid

1. Inadequate rate control: Atrial flutter is often more difficult to rate-control than atrial fibrillation 1

2. Neglecting anticoagulation: Atrial flutter carries thromboembolic risk similar to atrial fibrillation 3

3. Using class IC agents without rate control: These can slow flutter rate and paradoxically increase ventricular response due to decreased concealed conduction into the AV node 1

4. Overlooking electrolyte imbalances: Correct hypokalemia and hypomagnesemia before antiarrhythmic therapy, especially with drugs that prolong QT interval 5

5. Failing to recognize the high success rate of ablation: Catheter ablation offers >90% success with low complication rates and should be considered early in management 3