What is the treatment for atrial flutter?

Treatment of Atrial Flutter

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

Acute Management of Atrial Flutter

Hemodynamically Unstable Patients

1. Synchronized electrical cardioversion is the immediate treatment of choice for patients with hemodynamic instability 1
   • Lower energy levels are typically effective for atrial flutter compared to atrial fibrillation 1
   • No delay for pharmacological therapy attempts in unstable patients

Hemodynamically Stable Patients

Rate control options:

• First-line: Intravenous or oral beta blockers, diltiazem, or verapamil 1

  • IV diltiazem is often preferred due to its rapid onset and effectiveness 1, 2
  • Esmolol is the preferred IV beta blocker due to its rapid onset 1
  • Avoid calcium channel blockers in patients with:
    • Advanced heart failure
    • Heart block or sinus node dysfunction without pacemaker
    • Pre-excitation syndromes 1

• Second-line: IV amiodarone for rate control in patients with systolic heart failure when beta blockers are contraindicated or ineffective 1

Rhythm control options:

• Pharmacological cardioversion:

  • Oral dofetilide or IV ibutilide (Class I recommendation) 1
  • Flecainide or propafenone may be considered in patients without structural heart disease 1, 3, 4
    • Caution: These drugs can cause 1:1 AV conduction in atrial flutter, potentially increasing ventricular rate 3, 4

• Electrical cardioversion:

  • Highly effective (nearly 100%) 1, 5
  • Indicated when pursuing a rhythm-control strategy 1

• Rapid atrial pacing in patients with existing pacing wires 1

Long-term Management

Rhythm Control Options

1. Catheter ablation:

   • First-line for CTI-dependent flutter (>90% success rate) 1, 5, 6
   • Recommended for:
     • Symptomatic patients 1
     • Patients refractory to pharmacological rate control 1
     • Patients with recurrent symptomatic non-CTI-dependent flutter after failure of antiarrhythmic drugs 1
     • Patients undergoing AF ablation with history of atrial flutter 1
     • Patients with flutter induced by flecainide, propafenone, or amiodarone used for AF treatment 1

2. Antiarrhythmic medications for maintenance of sinus rhythm:

   • First-line: Amiodarone, dofetilide, or sotalol 1
   • Second-line: Flecainide or propafenone (only in patients without structural heart disease) 1, 3, 4

Rate Control Options

• Beta blockers, diltiazem, or verapamil for long-term rate control 1, 7
  • Selection based on comorbidities:
    • Beta blockers preferred in patients with ischemic heart disease, post-MI, hyperthyroidism 7
    • Calcium channel blockers preferred in patients with COPD/asthma 7

Anticoagulation

• Anticoagulation recommendations for atrial flutter align with those for atrial fibrillation 1
• Required before cardioversion if flutter duration ≥48 hours or unknown 1
• Long-term anticoagulation based on thromboembolic risk assessment 1

Important Considerations and Pitfalls

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

• Risk factors for developing AF after flutter ablation:

  • Prior AF history
  • Depressed left ventricular function
  • Structural heart disease
  • Ischemic heart disease
  • Inducible AF
  • Increased left atrial size 1

• Medication cautions:

  • Flecainide and propafenone can cause 1:1 AV conduction in atrial flutter, potentially increasing ventricular rate 3, 4
  • Concomitant AV nodal blocking agents recommended when using these drugs 4
  • Avoid beta blockers, calcium channel blockers, and digoxin in patients with Wolff-Parkinson-White syndrome and atrial flutter 7