What is the treatment for atrial flutter?

Treatment for Atrial Flutter

The most effective treatment for atrial flutter is catheter ablation of the cavotricuspid isthmus (CTI), with success rates exceeding 90% for long-term rhythm control in patients with symptomatic atrial flutter or those refractory to pharmacological management. 1

Initial Management Based on Hemodynamic Status

• For hemodynamically unstable patients, immediate synchronized cardioversion is recommended without delay 2, 3
• Cardioversion for atrial flutter can be successful at lower energy levels than for atrial fibrillation 2, 3
• For hemodynamically stable patients, management follows either a rate control or rhythm control strategy 2

Rate Control Strategy

• Intravenous diltiazem is the preferred calcium channel blocker for acute rate control due to its safety and efficacy profile 2, 3
• Esmolol is generally the preferred intravenous beta blocker for acute rate control because of its rapid onset 2
• Important medication considerations:
  • Avoid diltiazem and verapamil in patients with advanced heart failure, heart block, or sinus node dysfunction without pacemaker therapy 2, 3
  • Avoid both calcium channel blockers and beta blockers in patients with pre-excitation 3
  • For patients with atrial flutter and systolic heart failure where beta blockers are contraindicated or ineffective, intravenous amiodarone can be useful 3
• Target heart rate should be <100 beats per minute at rest 4

Rhythm Control Strategy

Acute Rhythm Control Options

• Elective synchronized cardioversion is indicated in stable patients when pursuing rhythm control 2, 1
• Pharmacological cardioversion options:
  • Oral dofetilide or intravenous ibutilide (effective in approximately 60% of cases) 2, 1
  • Flecainide and propafenone can be used in patients without structural heart disease 1
  • Caution with ibutilide due to risk of QT prolongation and torsades de pointes 3
• Rapid atrial pacing is useful for acute conversion in patients with pacing wires already in place 3, 1

Long-Term Rhythm Control Strategies

• Catheter ablation of the CTI is the most effective long-term rhythm control strategy with success rates >90% 2, 1
• The American College of Cardiology recommends CTI ablation as first-line therapy for CTI-dependent atrial flutter that is symptomatic or refractory to pharmacological rate control 1
• Antiarrhythmic medications for maintenance of sinus rhythm:
  • For patients with normal heart: dronedarone, flecainide, propafenone, or sotalol 4
  • For patients with abnormal ventricular function but LVEF >35%: dronedarone, sotalol, or amiodarone 4
  • For patients with LVEF <35%: amiodarone is usually the only recommended option 4

Anticoagulation Considerations

• Antithrombotic therapy in patients with atrial flutter should follow the same protocols as for atrial fibrillation 2, 1
• Risk of stroke in atrial flutter is significant, with reported rates of 3% annually 2, 3
• For atrial flutter ≥48 hours or unknown duration, anticoagulation is recommended for at least 3 weeks before and 4 weeks after cardioversion 1, 5
• Target INR of 2.0-3.0 is recommended for patients requiring anticoagulation 5

Important Clinical Considerations and Pitfalls

• Rate control can be more difficult to achieve in atrial flutter than in atrial fibrillation due to less concealed AV nodal conduction 2, 3
• Atrial flutter and atrial fibrillation frequently coexist—22-50% of patients develop atrial fibrillation within 14-30 months after CTI ablation 2, 1
• Risk factors for developing atrial fibrillation after atrial flutter ablation include:
  • Prior atrial fibrillation
  • Depressed left ventricular function
  • Structural heart disease
  • Increased left atrial size 2, 1
• Avoid using verapamil or diltiazem in patients with pre-excitation, which can precipitate ventricular fibrillation 3
• Monitor for QT prolongation when using ibutilide for pharmacological cardioversion 3