What is the management of atrial flutter?

Management of Atrial Flutter

Catheter ablation of the cavotricuspid isthmus (CTI) is the recommended first-line treatment for patients with symptomatic atrial flutter or flutter that is refractory to pharmacological rate control. 1

Acute Management

Rate Control

• Beta blockers, diltiazem, or verapamil are first-line agents for acute rate control in hemodynamically stable patients with atrial flutter 1
• In patients with systolic heart failure where beta blockers are contraindicated or ineffective, intravenous amiodarone can be used for acute rate control 1
• Higher doses of rate control medications are often needed in atrial flutter compared to atrial fibrillation due to paradoxically faster AV nodal conduction 1
• Beta blockers are preferred in patients with heart failure 1
• Avoid beta blockers, diltiazem, and verapamil in patients with pre-excited atrial flutter due to risk of accelerated ventricular rates and ventricular fibrillation 1

Rhythm Control

• For hemodynamically unstable patients, synchronized cardioversion is recommended 1
• Elective synchronized cardioversion is indicated in stable patients when pursuing rhythm control 1
• Intravenous ibutilide is effective for acute pharmacological cardioversion 1
• Rapid atrial pacing is useful for acute conversion in patients with pacing wires already in place 1

Anticoagulation

• Anticoagulation recommendations for atrial flutter are the same as for atrial fibrillation 1
• For flutter lasting <48 hours in low-risk patients, anticoagulation should be started before or immediately after cardioversion 1
• For flutter lasting ≥48 hours or unknown duration, anticoagulation should be given for at least 3 weeks before cardioversion or a transesophageal echocardiogram should be performed to exclude thrombus 1
• Following cardioversion, anticoagulation should be continued for at least 4 weeks 1
• Long-term anticoagulation decisions should be based on the patient's thromboembolic risk profile using the same criteria as for atrial fibrillation 1

Long-term Management

Catheter Ablation

• Catheter ablation of the CTI is highly effective (>90% success rate) for typical atrial flutter and is the preferred long-term management strategy 1
• Catheter ablation is also recommended for recurrent symptomatic non-CTI-dependent flutter after failure of at least one antiarrhythmic drug 1
• Catheter ablation is reasonable as primary therapy for recurrent symptomatic non-CTI-dependent flutter before trials of antiarrhythmic drugs 1
• Catheter ablation may be considered in asymptomatic patients with recurrent atrial flutter 1

Pharmacological Rhythm Control

• If catheter ablation is not an option, the following drugs can be useful to maintain sinus rhythm:
  • Amiodarone 1
  • Dofetilide 1
  • Sotalol 1
• Flecainide or propafenone may be considered in patients without structural heart disease 1
• Antiarrhythmic drugs alone control atrial flutter in only 50-60% of patients 2

Pharmacological Rate Control

• For chronic rate control, oral beta blockers, diltiazem, or verapamil are recommended 1
• Often combination therapy is needed to achieve adequate rate control 1
• AV nodal ablation with permanent ventricular pacing is reasonable when pharmacological therapy is inadequate and rhythm control is not achievable 1

Special Considerations

Pre-excitation Syndromes

• Avoid AV nodal blocking agents (beta blockers, calcium channel blockers, digoxin) in patients with pre-excited atrial flutter 1
• Direct current cardioversion is recommended for patients with pre-excitation and hemodynamic instability 1

Anticoagulation Management

• Warfarin with a target INR of 2.0-3.0 is recommended for patients with atrial flutter and risk factors for stroke 3
• The risk of stroke in patients with atrial flutter is similar to that in atrial fibrillation, with thromboembolism rates averaging 3% annually 1
• Meta-analysis of 13 studies reported short-term stroke risks ranging from 0% to 7% in patients undergoing cardioversion of atrial flutter 1

Common Pitfalls and Caveats

• Rate control can be more difficult to achieve in atrial flutter than in atrial fibrillation 1
• Conversion of atrial flutter to atrial fibrillation may occur with antiarrhythmic drugs 1
• Patients with atrial flutter often have coexisting atrial fibrillation, requiring comprehensive management of both arrhythmias 4, 2
• When using class IC antiarrhythmic drugs (flecainide, propafenone) for rhythm control, concomitant AV nodal blocking drugs should be administered to prevent rapid ventricular rates if flutter occurs 1