What is the management approach for atrial flutter?

Management of Atrial Flutter

Catheter ablation of the cavotricuspid isthmus is the most effective first-line treatment for symptomatic or recurrent atrial flutter, with success rates exceeding 90% for typical flutter. 1

Acute Management Based on Hemodynamic Status

Hemodynamically Unstable Patients

• Immediate synchronized electrical cardioversion (Class I recommendation)
  • Indicated for patients with hypotension, ongoing ischemia, or heart failure symptoms
  • Should be performed without delay if patient shows signs of hemodynamic compromise 1

Hemodynamically Stable Patients

• Rate control is the first-line approach:
  • First-line IV medications (Class I):
    • Diltiazem (0.25 mg/kg IV bolus over 2 minutes, followed by 5-15 mg/h) 1
    • Verapamil (0.075-0.15 mg/kg IV over 2 minutes) 1
    • Esmolol (500 mcg/kg IV over 1 minute, followed by 60-200 mcg/kg/min) 1
    • Metoprolol (2.5-5 mg IV bolus over 2 minutes, up to 3 doses) 1
    • Digoxin (0.25 mg IV every 2 hours, up to 1.5 mg) - primarily for patients with heart failure 1

Definitive Management Options

Catheter Ablation

• Radiofrequency catheter ablation of the cavotricuspid isthmus (Class I recommendation)
  • Success rate >90% for typical flutter 1
  • Preferred first-line treatment for symptomatic or recurrent atrial flutter 1
  • Avoids long-term toxicity associated with antiarrhythmic drugs 2

Pharmacological Cardioversion

• Options include:
  • Dofetilide (oral)
  • Ibutilide (IV) - more effective than sotalol for conversion of atrial flutter (70% vs 19%) 3
  • Class III agents (dofetilide, ibutilide) are more effective than class I agents or amiodarone for conversion 3

Electrical Cardioversion

• Elective synchronized cardioversion (Class I)
  • Success rate between 95-100% 3
  • Can often be achieved with relatively small amounts of energy (5-50 joules), especially with biphasic waveforms 3

Atrial Overdrive Pacing

• Rapid atrial pacing (Class I)
  • Particularly useful in post-cardiac surgery patients with epicardial atrial pacing wires 3
  • Cumulative success rate of 82% (range 55-100%) 3
  • Antiarrhythmic drugs may facilitate conversion by pacing 3

Long-Term Management

Maintaining Sinus Rhythm

• Antiarrhythmic medications (Class IIa):
  • Amiodarone
  • Dofetilide
  • Sotalol 1
  • Class IC agents (flecainide, propafenone) - but must be used with AV nodal blocking agents to prevent 1:1 conduction if flutter recurs 3

Long-Term Rate Control

• Oral medications:
  • Beta blockers
  • Calcium channel blockers
  • Digoxin (particularly in heart failure patients) 1

Anticoagulation

• Anticoagulation therapy (Class I):
  • Required for at least 3 weeks before and 4 weeks after cardioversion if flutter duration ≥48 hours
  • Long-term anticoagulation based on thromboembolic risk profile 1
  • Atrial flutter carries significant stroke risk similar to atrial fibrillation 1

Special Considerations

Wolff-Parkinson-White Syndrome

• Avoid AV nodal blocking agents (beta blockers, calcium channel blockers, digoxin)
  • These can facilitate antegrade conduction along the accessory pathway during atrial flutter 3
  • Can result in acceleration of ventricular rate, hypotension, or ventricular fibrillation 3
• Recommended treatments:
  • Type I antiarrhythmic agents or amiodarone may be administered intravenously in hemodynamically stable patients 3
  • Immediate direct-current cardioversion for hemodynamic compromise 3

Heart Failure Patients

• Avoid nondihydropyridine calcium channel antagonists and dronedarone in decompensated heart failure 3
• Preferred agents:
  • Beta blockers (due to favorable effects on morbidity and mortality) 3
  • Digoxin as an effective adjunct 3
• Consider AV node ablation and cardiac resynchronization therapy device placement when rate control cannot be achieved due to drug inefficacy or intolerance 3

Comorbid Conditions

• Beta-blockers are preferred for patients with myocardial ischemia or infarction 1, 4
• Calcium channel blockers are preferred for patients with COPD or asthma 1, 4

Remember that propafenone should not be used to control ventricular rate during atrial flutter 5, and when using class IC agents, always co-administer AV nodal blocking drugs to prevent rapid ventricular rates if atrial flutter develops 3.