What is the treatment for atrial flutter?

Treatment of Atrial Flutter

Synchronized cardioversion is the treatment of choice for hemodynamically unstable patients with atrial flutter, and should be performed without delay in patients with signs or symptoms of hemodynamic compromise. 1, 2

Approach Based on Hemodynamic Status

Unstable Patients

• Immediate synchronized cardioversion is recommended for patients with atrial flutter who are hemodynamically unstable and do not respond to pharmacological therapies 1
• Cardioversion for atrial flutter can be successful at lower energy levels than for atrial fibrillation 1
• Appropriate anticoagulation considerations should be addressed prior to cardioversion when possible 2

Stable Patients

Treatment depends on whether the goal is rate control or rhythm control:

Rate Control Strategy

• Intravenous or oral beta blockers (metoprolol, esmolol, propranolol), diltiazem, or verapamil are first-line agents for acute rate control in hemodynamically stable patients 1, 2
• Intravenous diltiazem is often preferred among calcium channel blockers due to its safety and efficacy profile 2
• Rate control is typically more difficult to achieve in atrial flutter than in atrial fibrillation 2
• For patients with atrial flutter and systolic heart failure where beta blockers are contraindicated or ineffective, intravenous amiodarone can be useful for acute rate control 1, 2

Rhythm Control Strategy

• Elective synchronized cardioversion is indicated in stable patients when pursuing a rhythm-control strategy 1
• Pharmacological cardioversion options include:
  • Oral dofetilide or intravenous ibutilide, which are effective for acute pharmacological cardioversion 1, 2
  • Flecainide and propafenone can be considered for patients without structural heart disease 1, 3
• Rapid atrial pacing is useful for acute conversion in patients with pacing wires already in place (e.g., permanent pacemaker, ICD, or temporary wires after cardiac surgery) 1, 2

Anticoagulation Considerations

• Acute antithrombotic therapy is recommended in patients with atrial flutter, following the same protocols as for atrial fibrillation 1
• The risk of stroke in atrial flutter is similar to that in atrial fibrillation, with thromboembolism rates averaging 3% annually in patients with sustained atrial flutter 1, 2
• For atrial flutter ≥48 hours or unknown duration, anticoagulation is recommended for at least 3 weeks before and 4 weeks after cardioversion 1

Long-term Management

• Catheter ablation of the cavotricuspid isthmus (CTI) is useful in patients with atrial flutter that is either symptomatic or refractory to pharmacological rate control 1
• CTI ablation has a high success rate (>90%) and avoids long-term toxicity associated with antiarrhythmic drugs 4
• For maintenance of sinus rhythm in patients with symptomatic recurrent atrial flutter, the following drugs can be useful depending on underlying heart disease and comorbidities:
  • Amiodarone
  • Dofetilide
  • Sotalol 1
• Flecainide or propafenone may be considered to maintain sinus rhythm in patients without structural heart disease 1, 5, 3

Special Considerations

• In patients with pre-excitation (Wolff-Parkinson-White syndrome), avoid AV nodal blocking agents (beta blockers, calcium channel blockers, digoxin) as they can facilitate antegrade conduction along the accessory pathway, potentially leading to ventricular fibrillation 1, 2
• When using flecainide or propafenone for atrial flutter, concomitant AV nodal blocking drugs should be administered to prevent 1:1 AV conduction that can lead to a very rapid ventricular response 1, 3
• Atrial flutter and atrial fibrillation often coexist in the same patient, with 22-50% of patients developing atrial fibrillation within 14-30 months after CTI ablation for atrial flutter 1

Common Pitfalls to Avoid

• Failing to recognize hemodynamic instability requiring immediate cardioversion 2
• Using verapamil or diltiazem in patients with pre-excitation, which can precipitate ventricular fibrillation 2
• Inadequate rate control, which is more challenging in atrial flutter than in atrial fibrillation 2
• Underestimating stroke risk in atrial flutter patients 2
• Using flecainide or propafenone without concomitant AV nodal blocking agents, which can lead to 1:1 AV conduction and dangerous acceleration of ventricular rate 3