What is the management of atrial flutter?

Management of Atrial Flutter

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

Acute Management

Hemodynamically Unstable Patients

• Immediate synchronized cardioversion is indicated for patients with hemodynamic instability 1
• No delay for pharmacological therapies if patient is compromised

Hemodynamically Stable Patients

Rate Control Options

1. First-line medications:

   • Intravenous diltiazem - preferred calcium channel blocker for acute rate control due to safety and efficacy 1
   • Intravenous beta-blockers (particularly esmolol due to rapid onset) 1
   • Intravenous verapamil - alternative to diltiazem 1

   Recent evidence shows diltiazem achieves more rapid rate control than metoprolol (95.8% vs 46.4% reaching target heart rate <100 bpm within 30 minutes) 2

2. Second-line options:

   • Intravenous amiodarone - useful when beta-blockers are contraindicated or ineffective, especially in patients with systolic heart failure 1
   • Digoxin - less effective for acute rate control but may be used in combination with other agents 3

Rhythm Control Options

1. Pharmacological cardioversion:

   • Intravenous ibutilide - effective for acute conversion of atrial flutter 1
   • Success rates up to 70% 4
   • Caution: monitor for QT prolongation and risk of torsades de pointes

2. Electrical cardioversion:

   • Nearly 100% effective 4
   • Lower energy requirements than for atrial fibrillation 1
   • Recommended when pursuing rhythm control strategy 1

3. Rapid atrial pacing:

   • Useful when pacing wires are already in place (post-cardiac surgery or with implanted devices) 1
   • Effective in >50% of cases 1

Anticoagulation

• Acute antithrombotic therapy should follow the same guidelines as for atrial fibrillation 1
• For cardioversion of atrial flutter lasting ≥48 hours, anticoagulation is required for at least 3 weeks before and 4 weeks after cardioversion unless transesophageal echocardiography excludes thrombus 1

Long-Term Management

Rate Control Strategy

• Beta-blockers, diltiazem, or verapamil for chronic rate control 1
• Often requires higher doses or combination therapy compared to atrial fibrillation 1
• Beta-blockers preferred in patients with heart failure 1
• Avoid beta-blockers, diltiazem, and verapamil in patients with pre-excited atrial flutter (risk of accelerated ventricular rates) 1

Rhythm Control Strategy

1. Catheter ablation:

   • First-line therapy for recurrent symptomatic atrial flutter 1

   • 90% success rate for typical (CTI-dependent) flutter 4

   • 70-90% success for atypical flutter 4
   • Reasonable in patients undergoing AF ablation who also have documented CTI-dependent flutter 1

2. Antiarrhythmic medications (if ablation not feasible):

   • Amiodarone - effective but has significant long-term toxicity 1
   • Dofetilide - effective for maintaining sinus rhythm 1
   • Sotalol - effective for maintaining sinus rhythm 1
   • Flecainide or propafenone - may be considered in patients without structural heart disease 1
     • Warning: These drugs may convert flutter to 1:1 conduction, requiring concomitant AV nodal blocking drugs 5, 6

3. Long-term anticoagulation:

   • Follow same risk stratification as for atrial fibrillation 1
   • Meta-analysis shows annual thromboembolism rate of approximately 3% in patients with sustained flutter 1

Special Considerations

Wolff-Parkinson-White Syndrome with Atrial Flutter

• Avoid AV nodal blocking agents (beta-blockers, calcium channel blockers, digoxin) 1
• These can facilitate conduction through accessory pathway, potentially causing ventricular fibrillation 1
• Immediate cardioversion for hemodynamic compromise 1
• Catheter ablation of accessory pathway recommended 1

Heart Failure Patients

• Beta-blockers preferred for rate control 1
• Amiodarone can be useful when beta-blockers are contraindicated 1
• Avoid non-dihydropyridine calcium channel blockers (diltiazem, verapamil) in decompensated heart failure 1

AV Nodal Ablation

• Consider when pharmacological rate control fails 1
• Requires permanent pacemaker implantation 1
• Provides effective heart rate control and improves symptoms in selected patients 1

Common Pitfalls

• Underestimating difficulty of rate control - atrial flutter often requires higher doses or combinations of rate-controlling medications compared to atrial fibrillation 1
• Using flecainide/propafenone without AV nodal blocking drugs - can lead to 1:1 conduction and dangerous acceleration of ventricular rate 5, 6
• Inadequate anticoagulation - atrial flutter carries significant stroke risk similar to atrial fibrillation 1
• Treating symptoms without addressing underlying cause - identify and treat precipitating factors (thyroid disease, pulmonary disease, etc.)