What is the treatment for atrial flutter?

Treatment for Atrial Flutter

Catheter ablation of the cavotricuspid isthmus (CTI) is the most effective treatment for atrial flutter, particularly for symptomatic patients or those refractory to pharmacological rate control. 1

Acute Management of Atrial Flutter

Hemodynamically Unstable Patients

• Synchronized cardioversion is recommended for immediate treatment of patients with atrial flutter who are hemodynamically unstable 1
• Initial energy levels can be lower than for atrial fibrillation (typically <50 joules with monophasic shocks, and even less with biphasic shocks) 1

Hemodynamically Stable Patients

1. Rate Control Options:

   • First-line: Intravenous or oral beta blockers (metoprolol, esmolol), diltiazem, or verapamil 1
     • IV diltiazem may be more effective than metoprolol for rapid rate control (95.8% vs 46.4% reaching target heart rate <100 bpm within 30 minutes) 2
     • Beta blockers are preferred in patients with myocardial ischemia, myocardial infarction, or hyperthyroidism 3
     • Calcium channel blockers are preferred in patients with bronchial asthma or COPD 3
   • For patients with heart failure: IV amiodarone when beta blockers are contraindicated or ineffective 1

2. Rhythm Control Options:

   • Pharmacological cardioversion:

     • Oral dofetilide or IV ibutilide (first-line agents) 1
     • IV ibutilide has shown 38-76% efficacy for conversion to sinus rhythm 1
     • Caution: Monitor for QT prolongation and risk of torsades de pointes

   • Electrical cardioversion:

     • Elective synchronized cardioversion for stable patients pursuing rhythm control 1

   • Rapid atrial pacing:

     • Useful for conversion in patients with existing pacemakers or temporary pacing wires 1

3. Antithrombotic therapy:

   • Follow the same anticoagulation guidelines as for atrial fibrillation 1
   • For cardioversion of atrial flutter lasting >48 hours, anticoagulation is required prior to the procedure 1

Long-Term Management

Catheter Ablation

• First-line therapy for symptomatic or recurrent atrial flutter 1
• Success rates >90% for typical CTI-dependent flutter 4
• Reasonable for asymptomatic patients with recurrent atrial flutter 1
• Particularly indicated when:
  • Flutter is refractory to pharmacological rate control 1
  • Flutter occurs as a result of medications used for AF (flecainide, propafenone, amiodarone) 1
  • Patient is undergoing catheter ablation for AF and has history of atrial flutter 1

Pharmacological Management

1. Rate control:

   • Beta blockers, diltiazem, or verapamil for ongoing ventricular rate control 1

2. Rhythm maintenance:

   • For symptomatic recurrent atrial flutter, consider:
     • Amiodarone, dofetilide, or sotalol (Class IIa recommendation) 1
     • Flecainide or propafenone may be considered in patients without structural heart disease (Class IIb) 1
     • Drug selection depends on underlying heart disease and comorbidities 1

3. Ongoing anticoagulation:

   • Follow the same guidelines as for atrial fibrillation, based on stroke risk assessment (CHADS-VASc score) 1
   • With CHADS-VASc score ≥2 in males or ≥3 in females, anticoagulation is clearly recommended 1

Special Considerations

• Atrial flutter with pre-excitation (WPW): Avoid AV nodal blocking agents (beta blockers, calcium channel blockers, digoxin) as they can precipitate ventricular fibrillation 3

• Risk of developing atrial fibrillation: 22-50% of patients develop AF within 14-30 months after CTI ablation for atrial flutter, with one study reporting 82% within 5 years 1

  • Risk factors: prior AF, depressed left ventricular function, structural heart disease, inducible AF, and increased left atrial size 1

• Rate control challenges: Heart rate can be more difficult to control in atrial flutter than in atrial fibrillation 1

• Monitoring: Patients receiving ibutilide should undergo continuous ECG monitoring during administration and for at least 4 hours afterward due to risk of torsades de pointes 1