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), which is the definitive long-term rhythm control strategy with success rates over 90% for typical atrial flutter. 1, 2

Initial Management Based on Hemodynamic Status

• For hemodynamically unstable patients: Immediate synchronized cardioversion is recommended without delay 1, 3

  • Atrial flutter typically responds to lower energy levels than atrial fibrillation 1, 3
  • Anticoagulation should be addressed prior to cardioversion when possible 1, 3

• For hemodynamically stable patients: Treatment focuses on rate control, rhythm control, and anticoagulation 2, 3

Rate Control Strategy

• First-line agents for acute rate control in hemodynamically stable patients:

  • Intravenous diltiazem (preferred calcium channel blocker due to safety and efficacy profile) 1, 2, 4
  • Intravenous esmolol (preferred beta-blocker due to rapid onset) 1
  • Oral beta-blockers or calcium channel blockers for ongoing management 2, 5

• Important medication considerations:

  • Avoid diltiazem and verapamil in patients with advanced heart failure, heart block, or sinus node dysfunction without pacemaker therapy 1, 3
  • For patients with systolic heart failure where beta-blockers are contraindicated or ineffective, intravenous amiodarone can be used 2, 3
  • Avoid calcium channel blockers and beta-blockers in patients with pre-excitation (Wolff-Parkinson-White syndrome) 2, 3
  • Digoxin is not recommended as monotherapy for rate control in active patients 5

• Rate control is often more difficult to achieve in atrial flutter than in atrial fibrillation due to less concealed AV nodal conduction 1, 3

Rhythm Control Strategy

• Electrical cardioversion:

  • Elective synchronized cardioversion is indicated in stable patients when pursuing rhythm control 1, 2, 3
  • Nearly 100% effective and ideal for patients with left ventricular dysfunction 6

• Pharmacological cardioversion options:

  • Oral dofetilide or intravenous ibutilide (effective in approximately 60% of cases) 1, 2, 3
  • Ibutilide requires caution 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

• Long-term rhythm maintenance:

  • Antiarrhythmic drugs (sotalol, amiodarone, dofetilide, propafenone, flecainide) may maintain sinus rhythm in 50-60% of patients 6
  • Propafenone is indicated to prolong time to recurrence of paroxysmal atrial flutter in patients without structural heart disease 7
  • Flecainide is not recommended for use in patients with chronic atrial flutter due to risk of ventricular proarrhythmic effects 8
  • Intermittent "pill in the pocket" antiarrhythmic therapy may be considered for infrequent, symptomatic episodes 5

• Catheter ablation:

  • Most effective long-term rhythm control strategy with >90% success rate for typical (cavotricuspid isthmus-dependent) flutter 1, 6, 9
  • Recommended for patients with symptomatic atrial flutter or those refractory to pharmacological rate control 2
  • Success rates of 70-90% for atypical flutter 6

Anticoagulation Considerations

• Antithrombotic therapy in patients with atrial flutter should follow the same protocols as for atrial fibrillation 1, 2, 3
• Risk of stroke in atrial flutter is significant, with reported rates of 3% annually 1, 2, 3
• Anticoagulation with warfarin should be considered in patients with recurrent atrial flutter, especially those over 70 years of age, and those with history of atrial fibrillation, stroke, or structural heart disease 6

Special Considerations

• Atrial flutter and atrial fibrillation frequently coexist—22-50% of patients develop atrial fibrillation within 14-30 months after CTI ablation 1, 2
• Risk factors for developing atrial fibrillation after atrial flutter ablation include prior atrial fibrillation, depressed left ventricular function, structural heart disease, and increased left atrial size 1
• When using flecainide or propafenone for atrial flutter, concomitant AV nodal blocking therapy is recommended to prevent 1:1 AV conduction that can lead to dangerously rapid ventricular rates 7, 8