What is the treatment for atrial flutter?

Treatment of Atrial Flutter

Catheter ablation of the cavotricuspid isthmus (CTI) is the recommended first-line treatment for symptomatic or recurrent atrial flutter, with success rates exceeding 90%. 1

Acute Management

Rate Control

1. First-line agents:

   • IV beta-blockers:
     • Esmolol (500 mcg/kg IV bolus, followed by 60-200 mcg/kg/min)
     • Metoprolol (2.5-5 mg IV bolus, up to 3 doses) 1
   • IV calcium channel blockers:
     • Diltiazem (0.25 mg/kg IV bolus, followed by 5-15 mg/h)
     • Verapamil (0.075-0.15 mg/kg IV) 1
     • Note: Diltiazem has been shown to be more effective than metoprolol in achieving rapid rate control 2

2. Second-line agent:

   • IV amiodarone (useful when beta-blockers are contraindicated or ineffective, especially in patients with systolic heart failure) 3, 1

Rhythm Control

1. Electrical cardioversion:

   • First-line approach for hemodynamically unstable patients
   • Highly effective (91% success rate) with higher discharge rates (93%) compared to pharmacological cardioversion 4
   • Requires appropriate anticoagulation if atrial flutter duration ≥48 hours 3

2. Pharmacological cardioversion:

   • Ibutilide or dofetilide (Class I recommendation for patients with atrial flutter) 1
   • Amiodarone (Class IIa recommendation) 1
   • Flecainide or propafenone may be considered for patients without structural heart disease 1, 5, 6
     • Caution: Must be combined with AV nodal blocking agents due to risk of 1:1 AV conduction 1, 6
     • Warning: Flecainide is contraindicated in patients with structural heart disease due to increased mortality risk 6

3. Overdrive pacing:

   • Can be useful when sedation is contraindicated or in setting of digitalis toxicity 3

Anticoagulation

Anticoagulation recommendations for atrial flutter are the same as for atrial fibrillation:

• Required for at least 3 weeks before and 4 weeks after cardioversion if flutter duration ≥48 hours 1
• Long-term anticoagulation based on CHA₂DS₂-VASc score 1
• Meta-analysis of 13 studies showed short-term stroke risks ranging from 0% to 7% in patients undergoing cardioversion 3

Long-term Management

1. Catheter ablation:

   • First-line therapy for symptomatic or recurrent atrial flutter 3, 1
   • Targets the cavotricuspid isthmus (CTI) with success rates >90% 1, 7
   • Preferred over long-term pharmacological therapy 3

2. Pharmacological options (if ablation not feasible):

   • Beta-blockers or non-dihydropyridine calcium channel blockers for rate control 1, 8
   • Flecainide or propafenone for rhythm control in patients without structural heart disease 1, 5
   • Amiodarone for rhythm control in patients with structural heart disease 1

Important Caveats

• Never use flecainide or propafenone without AV nodal blocking agents due to risk of 1:1 AV conduction 1, 6
• Avoid flecainide in patients with structural heart disease due to increased mortality risk demonstrated in the CAST trial 6
• Propafenone should not be used to control ventricular rate during atrial flutter 5
• Monitor for tachycardia-mediated cardiomyopathy in persistent cases 1
• Evaluate for underlying causes such as pulmonary disease, thyroid dysfunction, or heart failure 1
• Recognize that atrial flutter carries significant stroke risk similar to atrial fibrillation 3, 1

By following this treatment algorithm, clinicians can effectively manage atrial flutter while minimizing complications and improving patient outcomes.