Does a patient with atrial flutter and a heart rate under 88 beats per minute (bpm) require hospital admission?

Management of Atrial Flutter with Heart Rate Under 88 BPM

Patients with atrial flutter and a heart rate under 88 beats per minute do not require hospital admission if they are hemodynamically stable and have no concerning symptoms or complications.

Assessment of Atrial Flutter Patients

When evaluating a patient with atrial flutter and a heart rate below 88 bpm, consider:

Hemodynamic Stability Assessment

• Vital signs (blood pressure, respiratory rate, oxygen saturation)
• Signs of poor perfusion (altered mental status, cool extremities)
• Presence of chest pain, dyspnea, or syncope

Risk Stratification

• Duration of arrhythmia (less than or greater than 48 hours)
• Presence of underlying structural heart disease
• Stroke risk using CHADS₂ score
• Comorbidities that may be exacerbated by atrial flutter

Management Decision Algorithm

1. For hemodynamically unstable patients (regardless of heart rate):

   • Immediate direct-current cardioversion is recommended 1
   • Hospital admission is necessary

2. For hemodynamically stable patients with heart rate <88 bpm:

   • Outpatient management is appropriate if:
     • No signs of heart failure or myocardial ischemia
     • No severe underlying structural heart disease
     • Adequate rate control (already achieved with rate <88 bpm)
     • No high-risk features requiring immediate intervention

3. Rhythm control considerations:

   • For stable patients with recent-onset atrial flutter (<48 hours):

     • Consider the "pill-in-the-pocket" approach for selected patients 1
     • Electrical cardioversion can be performed in the ED with discharge home if successful 2

   • For atrial flutter >48 hours or unknown duration:

     • Anticoagulation for 3 weeks before and 4 weeks after cardioversion 1
     • Rate control optimization first

Important Considerations

• Rate control: A heart rate <88 bpm indicates adequate rate control, which is a positive prognostic factor
• Anticoagulation: Assess stroke risk even though risk appears lower than with atrial fibrillation 3
• Follow-up: Arrange appropriate outpatient follow-up within 1-2 weeks

Pitfalls to Avoid

• Don't assume all slow atrial flutter is benign: Even with controlled rates, evaluate for underlying causes (medication effects, conduction disease)
• Don't overlook anticoagulation needs: Atrial flutter carries thromboembolic risk similar to atrial fibrillation
• Don't miss underlying heart disease: Atrial flutter may be the first presentation of structural heart disease

Evidence Summary

The ACC/AHA/ESC guidelines indicate that immediate hospitalization is primarily needed for hemodynamically unstable patients with atrial flutter 1. For stable patients with well-controlled heart rates (such as <88 bpm), outpatient management is appropriate. The Canadian Cardiovascular Society guidelines specifically note that most patients with recent-onset atrial flutter can be safely managed in the emergency department without hospital admission 4.

A study examining outcomes of ED patients with atrial flutter found low rates of adverse events (2.5% combined death/stroke at 1 year), with the majority of patients being safely discharged home 2. This supports outpatient management for hemodynamically stable patients with controlled heart rates.