Management of Atrial Flutter
Catheter ablation of the cavotricuspid isthmus is the most effective first-line treatment for symptomatic or recurrent atrial flutter, while acute management depends on hemodynamic stability with synchronized cardioversion for unstable patients and rate control medications for stable patients. 1
Acute Management Based on Hemodynamic Status
Hemodynamically Unstable Patients
- Immediate synchronized electrical cardioversion (Class I recommendation) for patients with:
- Hypotension
- Ongoing ischemia
- Heart failure symptoms 1
Hemodynamically Stable Patients
- Rate control as first-line treatment using:
- IV/oral beta blockers
- IV/oral non-dihydropyridine calcium channel blockers
- Digoxin (primarily for heart failure patients) 1
First-line IV medications for acute rate control:
- Diltiazem (0.25 mg/kg IV bolus over 2 minutes, followed by 5-15 mg/h)
- Verapamil (0.075-0.15 mg/kg IV over 2 minutes)
- Esmolol (500 mcg/kg IV over 1 minute, followed by 60-200 mcg/kg/min)
- Metoprolol (2.5-5 mg IV bolus over 2 minutes, up to 3 doses)
- Digoxin (0.25 mg IV every 2 hours, up to 1.5 mg) for patients with heart failure 1
Rhythm Control Options
Pharmacological Cardioversion
- Oral dofetilide
- IV ibutilide 1
Non-pharmacological Rhythm Control
- Elective synchronized cardioversion
- Rapid atrial pacing (for patients with pacing wires already in place)
- Catheter ablation of the cavotricuspid isthmus (>90% success rate for typical flutter) 1
Long-term Management
Maintaining Sinus Rhythm
- Amiodarone, dofetilide, and sotalol are recommended for maintaining sinus rhythm 1
- Class IC agents (flecainide, propafenone) may be used in patients without structural heart disease 1
- Note: When using flecainide for paroxysmal atrial flutter, start at 50 mg every 12 hours, increasing in increments of 50 mg bid every four days until efficacy is achieved (maximum 300 mg/day) 2
- Important: Concomitant AV nodal blocking drugs should be routinely co-administered with Class IC agents to prevent rapid ventricular response if atrial flutter develops 3
Long-term Rate Control
- Oral beta blockers
- Oral calcium channel blockers
- Digoxin 1
Anticoagulation
- Anticoagulation therapy for at least 3 weeks before and 4 weeks after cardioversion if flutter duration ≥48 hours
- Long-term anticoagulation based on thromboembolic risk profile (similar to atrial fibrillation) 1
- Continue anticoagulation based on risk profile even after successful ablation 1
Special Considerations
Wolff-Parkinson-White Syndrome
- AVOID digoxin, beta-blockers, and calcium channel blockers as they can facilitate antegrade conduction along the accessory pathway during atrial flutter 3, 1
- For hemodynamically stable patients with preexcitation, use:
- Type I antiarrhythmic agents
- Amiodarone (IV) 3
Heart Failure Patients
- AVOID non-dihydropyridine calcium channel blockers in decompensated heart failure 1
- Consider AV nodal ablation with permanent pacemaker implantation for patients with symptoms or tachycardia-mediated cardiomyopathy related to rapid ventricular rate that cannot be controlled with medications 3
- Recent evidence suggests rhythm control is superior to rate control for tachycardia-induced cardiomyopathy patients with persistent atrial flutter 4
Comorbid Conditions
- Beta-blockers are preferred for patients with myocardial ischemia or infarction
- Calcium channel blockers are preferred for patients with COPD or asthma 1, 5
Monitoring and Follow-up
- Monitor response to treatment and adjust therapy as needed
- Consider combination therapy or dose escalation if initial response is inadequate 1
- For patients on antiarrhythmic medications, monitor for proarrhythmic effects, especially when using Class IC agents in patients with structural heart disease 2