What is the management of atrial flutter?

Management of Atrial Flutter

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

Acute Management Algorithm

1. Initial Assessment and Stabilization

• Hemodynamically unstable patients:

  • Immediate synchronized electrical cardioversion is indicated 1
  • Use energy levels less than 50 joules with monophasic shocks (lower energy with biphasic shocks) 1

• Hemodynamically stable patients:

  • Proceed with rate control and/or rhythm control strategies

2. Rate Control for Stable Patients

• First-line medications:

  • Beta blockers (IV or oral): metoprolol, esmolol
  • Non-dihydropyridine calcium channel blockers (IV or oral): diltiazem, verapamil 1
  • Diltiazem may achieve more rapid rate control than metoprolol (95.8% vs 46.4% reaching target heart rate within 30 minutes) 2

• Second-line medication:

  • IV amiodarone can be useful when beta blockers are contraindicated or ineffective, particularly in patients with systolic heart failure 1

• Target heart rate: Initially aim for a lenient target of <110 beats/min at rest 1

3. Rhythm Control Strategies

• Pharmacological cardioversion:

  • Oral dofetilide or IV ibutilide are first-line agents for acute pharmacological cardioversion 1
  • IV ibutilide has shown 38-76% efficacy for conversion of atrial flutter to sinus rhythm 1

• Electrical cardioversion:

  • Elective synchronized cardioversion is indicated in stable patients when rhythm control is pursued 1

• Rapid atrial pacing:

  • Useful for acute conversion in patients with pacing wires in place 1

Long-term Management

1. Catheter Ablation

• Primary recommendation: Catheter ablation of the CTI is recommended for:

  • Symptomatic atrial flutter
  • Flutter refractory to pharmacological rate control 1
  • Patients undergoing AF ablation who have a history of documented clinical or induced CTI-dependent flutter 1

• Efficacy: Acutely successful in over 90% of cases 3

• Benefits: Avoids long-term toxicity associated with antiarrhythmic drugs 3

2. Antiarrhythmic Medications

For patients who cannot undergo ablation or prefer medical therapy:

• Recommended drugs to maintain sinus rhythm:

  • Amiodarone
  • Dofetilide
  • Sotalol 1

• Important caution: When using flecainide, propafenone, or amiodarone for AF treatment, patients may develop CTI-dependent atrial flutter 1

  • These class Ic agents may slow the flutter rate and cause paradoxical increase in ventricular response 1, 4
  • Always co-administer AV nodal blocking drugs (beta blockers or calcium channel blockers) when using these agents 1, 4

3. Anticoagulation

• Critical recommendation: Initiate anticoagulation in all patients with documented atrial flutter who have increased risk of stroke 1
• Risk assessment: Use CHADS-VASc score
  • Score ≥2 in males or ≥3 in females: anticoagulation clearly recommended
  • Score 1 in males or 2 in females: anticoagulation should be considered 1
• Duration:
  • Before cardioversion: Minimum 3 weeks of effective anticoagulation
  • After cardioversion: Minimum 4 weeks of anticoagulation required 1
  • For ongoing management: Follow same anticoagulation recommendations as for atrial fibrillation 1

Special Considerations

Wolff-Parkinson-White Syndrome

• Contraindicated medications: Beta blockers, digoxin, adenosine, and calcium channel blockers
  • These can facilitate antegrade conduction along the accessory pathway during atrial flutter, resulting in acceleration of ventricular rate, hypotension, or ventricular fibrillation 1
• Recommended approach: Early direct-current cardioversion for hemodynamic compromise 1

Pulmonary Disease

• Preferred rate control: Non-dihydropyridine calcium channel antagonists (diltiazem or verapamil) 1
• Contraindicated: Beta blockers, sotalol, propafenone, and adenosine in patients with obstructive lung disease 1

Post-operative Atrial Flutter

• Prevention: Perioperative oral beta-blockers 1
• Treatment: Restore sinus rhythm by cardioversion 1

Monitoring and Follow-up

• Monitor for development of atrial fibrillation, which occurs in 22-50% of patients after CTI ablation (up to 82% within 5 years) 1
• Risk factors for developing AF after atrial flutter ablation:
  • Prior AF
  • Depressed left ventricular function
  • Structural heart disease
  • Increased LA size 1

By following this comprehensive approach to atrial flutter management, clinicians can effectively control symptoms, prevent complications, and improve patient outcomes.