What is the treatment for atrial flutter?

Treatment of Atrial Flutter

Catheter ablation of the cavotricuspid isthmus (CTI) is the most effective treatment for atrial flutter and should be considered first-line therapy for symptomatic patients or those refractory to rate control. 1

Acute Management Algorithm

For Hemodynamically Unstable Patients:

• Immediate synchronized electrical cardioversion (Class I recommendation) 1
  • Usually effective with energies less than 50 joules (monophasic) and even less with biphasic shocks
  • No delay for anticoagulation if unstable

For Hemodynamically Stable Patients:

1. Rate Control

   • First-line medications (Class I recommendation) 1:
     • IV or oral beta blockers (e.g., metoprolol)
     • IV or oral diltiazem or verapamil
     • Avoid in patients with pre-excitation, severe heart failure, or significant hypotension

2. Rhythm Control Options:

   • Pharmacological cardioversion (Class I recommendation) 1:

     • Oral dofetilide or IV ibutilide (most effective for atrial flutter)
     • IV ibutilide converts approximately 60% of atrial flutter cases 1
     • Caution: Monitor for QT prolongation and torsades de pointes for at least 4 hours after administration

   • Electrical cardioversion (Class I recommendation) 1:

     • Highly effective (>90% success rate)
     • Requires procedural sedation

   • Rapid atrial pacing (Class I recommendation) 1:

     • Useful if patient has existing pacemaker or temporary pacing wires

3. Anticoagulation (Class I recommendation) 1:

   • Follow same protocols as for atrial fibrillation
   • If duration >48 hours or unknown, anticoagulate for ≥3 weeks before cardioversion or perform TEE-guided cardioversion
   • Continue anticoagulation for at least 4 weeks after cardioversion

Long-Term Management

First-Line Therapy:

• Catheter ablation of CTI (Class I recommendation) 1
  • Success rate >90%
  • Low complication rate
  • Most effective for preventing recurrence
  • Particularly indicated for:
    • Symptomatic patients
    • Patients refractory to rate control
    • Patients with atrial flutter occurring during treatment for AF with flecainide, propafenone, or amiodarone

Alternative Approaches:

1. Chronic rate control (Class I recommendation) 1:

   • Beta blockers, diltiazem, or verapamil
   • Often difficult to achieve adequate rate control with medications alone
   • May require combination therapy

2. Antiarrhythmic medications (Class IIa recommendation) 1:

   • Amiodarone
   • Dofetilide
   • Sotalol
   • Drug selection depends on underlying heart disease and comorbidities

Important Considerations and Pitfalls

• Risk of 1:1 AV conduction: Class IC antiarrhythmics (flecainide, propafenone) can slow atrial rate in flutter, potentially allowing 1:1 conduction and dangerous acceleration of ventricular rate 2, 3

  • Always co-administer AV nodal blocking agents when using these medications

• AF and flutter coexistence: 22-50% of patients with atrial flutter develop AF within 14-30 months after ablation, with up to 82% developing AF within 5 years 1

• Non-CTI dependent flutter: May occur after cardiac surgery or previous ablation and typically requires specialized mapping and ablation techniques 1

• Post-ablation recurrence: For atrial flutter occurring after AF ablation, consider waiting 3 months before attempting ablation as many cases resolve spontaneously 1

• Anticoagulation: Atrial flutter carries similar thromboembolic risk as atrial fibrillation and requires the same anticoagulation approach 1

By following this evidence-based approach to atrial flutter management, you can effectively reduce morbidity and mortality while improving quality of life for patients with this common arrhythmia.