What is the treatment for atrial flutter?

Treatment of Atrial Flutter

The most effective treatment for atrial flutter is catheter ablation of the cavotricuspid isthmus (CTI), which should be considered first-line therapy for symptomatic patients or those with flutter refractory to pharmacological rate control. 1, 2

Acute Management Based on Hemodynamic Status

Hemodynamically Unstable Patients

• Immediate synchronized cardioversion is recommended for patients with atrial flutter who are hemodynamically unstable 1, 2
• Cardioversion for atrial flutter can be successful at lower energy levels than for atrial fibrillation 1, 2
• Appropriate anticoagulation considerations should be addressed when possible 1, 2

Hemodynamically Stable Patients

Rate Control Strategy

• First-line agents for acute rate control include:
  • IV beta blockers (esmolol preferred due to rapid onset) 2, 3
  • IV diltiazem (preferred calcium channel blocker) 2, 3
  • IV verapamil 1, 4
• For patients with systolic heart failure where beta blockers are contraindicated or ineffective:
  • IV amiodarone can be useful for acute rate control 1, 3
• Important medication considerations:
  • Avoid diltiazem and verapamil in patients with advanced heart failure, heart block, or sinus node dysfunction without pacemaker therapy 3, 4
  • Avoid beta blockers, diltiazem, and verapamil in patients with pre-excited atrial flutter due to risk of accelerated ventricular rates 4

Rhythm Control Strategy

• Elective synchronized cardioversion is indicated in stable patients when pursuing rhythm control 2, 3
• Pharmacological cardioversion options:
  • Oral dofetilide or IV ibutilide (effective in approximately 60% of cases) 2, 4
  • Pretreatment with magnesium can increase ibutilide efficacy and reduce risk of torsades de pointes 4
• 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, 3

Long-Term Management

Rate Control Strategy

• Beta blockers, diltiazem, or verapamil are recommended for long-term rate control 1, 4
• Treatment should aim for a resting heart rate of <100 beats per minute 5
• Higher doses or combination therapy may be needed as rate control is often more difficult to achieve in atrial flutter than in atrial fibrillation 4, 6

Rhythm Control Strategy

• Catheter ablation of the CTI is the preferred definitive treatment for symptomatic atrial flutter or flutter refractory to pharmacological rate control (success rates >90%) 1, 2
• If pharmacological therapy is preferred:
  • Amiodarone, dofetilide, or sotalol can be useful to maintain sinus rhythm 1, 4
  • Flecainide or propafenone may be considered only in patients without structural heart disease 4, 7
  • Important warning: When using flecainide or propafenone for atrial flutter, concomitant AV nodal blocking agents are required due to risk of 1:1 AV conduction 7, 8

Anticoagulation Considerations

• Antithrombotic therapy in patients with atrial flutter should follow the same protocols as for atrial fibrillation 1, 2
• Risk of stroke in atrial flutter is significant, with reported rates of 3% annually 1, 3
• Anticoagulation should be continued in high-risk patients even after rhythm control is achieved 9

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 4, 6
• Atrial flutter and atrial fibrillation frequently coexist—22-50% of patients develop atrial fibrillation within 14-30 months after CTI ablation 2, 4
• 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, 4
• When using class IC antiarrhythmic drugs (flecainide, propafenone):
  • These drugs can slow atrial rate and facilitate 1:1 AV conduction, potentially increasing ventricular rate 7, 8
  • Always combine with AV nodal blocking agents 1, 8
  • Contraindicated in patients with structural heart disease 7, 8