From the Guidelines
The management of atrial flutter should prioritize catheter ablation of the cavo-tricuspid isthmus (CTI) for symptomatic or refractory patients, as well as anticoagulation therapy to reduce the risk of thromboembolism, as recommended by the most recent guidelines 1.
Key Management Strategies
- Catheter ablation: This procedure is useful in patients with atrial flutter that is either symptomatic or refractory to pharmacological rate control, with a success rate of 90-95% for typical flutter 1.
- Rate control: Beta blockers, diltiazem, or verapamil are useful to control the ventricular rate in patients with hemodynamically tolerated atrial flutter, with beta-blockers being a first-choice option for patients with left ventricular ejection fraction (LVEF) >40% 1.
- Rhythm control: Antiarrhythmic agents like amiodarone, dofetilide, or sotalol can be used to maintain sinus rhythm in patients with symptomatic, recurrent atrial flutter, with the choice of drug depending on underlying heart disease and comorbidities 1.
- Anticoagulation: Ongoing management with antithrombotic therapy is recommended in patients with atrial flutter to align with recommended antithrombotic therapy for patients with atrial fibrillation, using the CHA₂DS₂-VASc score to guide therapy 1.
Considerations for Specific Patient Populations
- Patients with recurrent symptomatic non-CTI-dependent flutter may benefit from catheter ablation as primary therapy, after carefully weighing potential risks and benefits of treatment options 1.
- Asymptomatic patients with recurrent atrial flutter may also be considered for catheter ablation, although the decision should be made on a case-by-case basis 1.
Important Medications and Dosing
- Beta blockers: metoprolol 5mg IV every 5 minutes up to 15mg, or oral dosing at 25-100mg twice daily 1.
- Calcium channel blockers: diltiazem 0.25mg/kg IV over 2 minutes, followed by infusion at 5-15mg/hour, or oral dosing at 30-60mg four times daily 1.
- Antiarrhythmic agents: amiodarone 150mg IV over 10 minutes, then 1mg/min for 6 hours, then 0.5mg/min, or other agents like dofetilide or sotalol, with dosing guided by individual patient characteristics and response 1.
From the FDA Drug Label
Among patients with atrial flutter, 53% receiving 1 mg ibutilide fumarate and 70% receiving 2 mg ibutilide fumarate converted, compared to 18% of those receiving sotalol. Electrical cardioversion was allowed 90 minutes after the infusion was complete. Conversion of atrial flutter/ fibrillation usually (70% of those who converted) occurred within 30 minutes of the start of infusion and was dose related.
The management of atrial flutter may include the use of ibutilide fumarate, with conversion rates of 53% and 70% for 1 mg and 2 mg doses, respectively 2. Electrical cardioversion may also be considered, allowed 90 minutes after the infusion is complete. Conversion usually occurs within 30 minutes of the start of infusion and is dose-related.
From the Research
Management of Atrial Flutter
The management of atrial flutter involves several goals, including:
- Achieving adequate rate control, which can be done using oral or intravenous digoxin, calcium channel blockers, or beta-blockers, alone or in combination 3
- Anticoagulation with warfarin, especially in patients over 70 years of age, and those with a history of atrial fibrillation, stroke, or structural heart disease 3
- Conversion to sinus rhythm, which can be achieved using intravenous ibutilide or direct-current cardioversion 3
- Long-term maintenance of sinus rhythm, which can be achieved using antiarrhythmic drugs, such as sotalol, amiodarone, dofetilide, propafenone, and flecainide, or radiofrequency catheter ablation 3, 4
Treatment Options
Treatment options for atrial flutter include:
- Electrical cardioversion, which is nearly 100% effective and ideal for patients with left ventricular dysfunction 3
- Antiarrhythmic medications, such as Type I and Type III antiarrhythmic drugs, which can be used to terminate or prevent recurrent episodes, and Type II and Type IV antiarrhythmic drugs, which can be used to control the ventricular rate during atrial flutter 4
- Radiofrequency catheter ablation, which can cure over 90% of patients with type 1 atrial flutter and 70-90% of patients with atypical atrial flutter 3, 4
- Pharmacologic treatment, which can be used to restore or maintain sinus rhythm, or control the ventricular response during tachyarrhythmia 5
Acute Ventricular Rate Control
Acute ventricular rate control in atrial flutter can be achieved using:
- Atrioventricular node blocking agents, such as beta-adrenergic blockers, non-dihydropyridine calcium channel blockers, and digoxin 6
- Intravenous beta-blockers and non-dihydropyridine calcium channel blockers, which are equally effective in rapidly controlling the ventricular rate 6
- Combination regimens, which can provide better ventricular rate control than any agent alone 6
Management in Specific Patient Populations
In patients with acute decompensated heart failure, the management of atrial flutter with rapid ventricular response is not well established, and high-level evidence to inform clinical decision making is lacking 7 In patients with atrial fibrillation with Wolff-Parkinson-White syndrome, beta-blockers, calcium channel blockers, and digoxin should be avoided, and procainamide or other antiarrhythmic drugs should be used instead 6