What are the treatment options for atrial flutter?

Treatment Options for Atrial Flutter

Catheter ablation is the first-line treatment for typical (isthmus-dependent) atrial flutter, with a success rate exceeding 90%. 1

Initial Management Approach

Rate Control

Rate control is essential in symptomatic patients with atrial flutter:

1. First-line agents for acute rate control:

   • 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)
   • 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

   Diltiazem has been shown to be more effective than metoprolol for rapid rate control, achieving target heart rate <100 bpm in 95.8% vs 46.4% of patients within 30 minutes 2

2. Maintenance rate control:

   • Oral beta-blockers (metoprolol, atenolol)
   • Non-dihydropyridine calcium channel blockers (diltiazem, verapamil)
   • Digoxin (less effective as monotherapy) 1, 3

Rhythm Control

1. Electrical cardioversion:

   • Nearly 100% effective for converting atrial flutter to sinus rhythm
   • Requires anticoagulation if flutter duration ≥48 hours (3 weeks before and 4 weeks after) 1

2. Pharmacological cardioversion options:

   • Ibutilide (Class IIa recommendation)
   • Dofetilide (Class I, Level A recommendation)
   • Amiodarone (Class IIa, Level A recommendation) 1

3. Maintenance of sinus rhythm:

   • For paroxysmal atrial flutter without structural heart disease:
     • Flecainide or propafenone (requires AV nodal blocking agent) 1, 4
   • For patients with structural heart disease:
     • Amiodarone
     • Sotalol
     • Dofetilide 1, 5

Definitive Treatment

Catheter ablation is highly effective for typical atrial flutter:

• Success rate >90% for typical (isthmus-dependent) flutter
• Success rate 70-90% for atypical flutter
• Avoids long-term toxicity associated with antiarrhythmic drugs 1, 6, 7

Anticoagulation

• CHA₂DS₂-VASc score should be used to assess thromboembolic risk
• Anticoagulation therapy is recommended for at least 3 weeks before and 4 weeks after cardioversion if flutter duration ≥48 hours
• Long-term anticoagulation is based on thromboembolic risk profile 1

Important Cautions and Contraindications

• Flecainide and propafenone:

  • CONTRAINDICATED in patients with structural heart disease or coronary artery disease
  • Can cause 1:1 atrioventricular conduction in atrial flutter, requiring concomitant AV nodal blocking agents
  • Flecainide is NOT RECOMMENDED for chronic atrial fibrillation/flutter 4, 8

• Calcium channel blockers (verapamil, diltiazem):

  • Avoid in patients with heart failure or pre-excitation syndromes 1, 3

• Special consideration for Wolff-Parkinson-White syndrome:

  • Beta-blockers, calcium channel blockers, and digoxin are CONTRAINDICATED as they can precipitate ventricular fibrillation 3

Monitoring and Follow-up

• Close monitoring during IV drug therapy for hypotension or bradycardia
• Long-term monitoring for tachycardia-mediated cardiomyopathy in persistent cases 1