What is the management of atrial flutter?

Management of Atrial Flutter

Acute Management

For hemodynamically unstable patients with atrial flutter, immediate synchronized cardioversion is the treatment of choice. 1, 2, 3 Cardioversion can be successful at lower energy levels than required for atrial fibrillation. 2

Rate Control in Stable Patients

For hemodynamically stable patients, initial management focuses on ventricular rate control:

First-line agents for acute rate control:

• Beta-blockers (metoprolol, esmolol, or propranolol) or non-dihydropyridine calcium channel blockers (diltiazem or verapamil) are recommended as first-line therapy. 1, 2, 3
• Esmolol is generally preferred among beta-blockers due to its rapid onset (5 minutes) and short half-life. 4, 2
• Diltiazem is the preferred calcium channel blocker due to its safety and efficacy profile, with onset in 2-7 minutes. 4, 2
• Higher doses of rate control medications are often needed in atrial flutter compared to atrial fibrillation due to paradoxically faster AV nodal conduction. 1

Special populations:

• In patients with systolic heart failure, beta-blockers are preferred due to favorable effects on morbidity and mortality. 3 If beta-blockers are contraindicated or ineffective, intravenous amiodarone can be used. 1
• Avoid diltiazem and verapamil in patients with decompensated heart failure, advanced heart block, or sinus node dysfunction without a pacemaker. 2, 3
• Digoxin may be used as an adjunct to beta-blockers or calcium channel blockers but is not recommended as monotherapy in active patients. 3, 5

Critical contraindication:

• Avoid beta-blockers, diltiazem, verapamil, and digoxin in patients with pre-excited atrial flutter (Wolff-Parkinson-White syndrome) as these can accelerate ventricular rates and precipitate ventricular fibrillation. 4, 1, 2

Rhythm Control Options

Pharmacological cardioversion:

• Intravenous ibutilide is effective for acute pharmacological cardioversion (approximately 60% success rate). 1, 2, 6
• Oral dofetilide is an alternative option for pharmacological cardioversion. 2
• Rapid atrial pacing is useful for acute conversion in patients with pacing wires already in place. 1

Elective synchronized cardioversion:

• Indicated in stable patients when pursuing rhythm control strategy. 1, 2
• Nearly 100% effective and ideal for patients with left ventricular dysfunction. 6

Anticoagulation

Anticoagulation recommendations for atrial flutter are identical to those for atrial fibrillation:

• 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, either:
  • Therapeutic anticoagulation for at least 3 weeks before cardioversion, OR
  • Transesophageal echocardiogram to exclude thrombus 1, 2
• Following cardioversion, continue anticoagulation for at least 4 weeks. 1, 2, 3
• Long-term anticoagulation decisions should be based on thromboembolic risk profile using the same criteria as atrial fibrillation (CHA₂DS₂-VASc score). 1, 2
• The risk of stroke in atrial flutter is similar to atrial fibrillation, averaging 3% annually. 1, 2

Long-term Management

Catheter ablation of the cavotricuspid isthmus (CTI) is the preferred long-term management strategy for typical atrial flutter:

• Success rate exceeds 90% for typical atrial flutter. 1, 6, 7
• Should be considered as primary therapy for recurrent symptomatic atrial flutter. 1
• For recurrent symptomatic non-CTI-dependent flutter, catheter ablation is recommended after failure of at least one antiarrhythmic drug. 1

Antiarrhythmic drug therapy (if ablation not an option):

• For patients without structural heart disease: Dronedarone, flecainide, propafenone, or sotalol can be used. 1, 8, 5
• For patients with abnormal ventricular function but LVEF >35%: Dronedarone, sotalol, or amiodarone. 1, 5
• For patients with LVEF <35%: Amiodarone is the only drug usually recommended. 1, 5
• Antiarrhythmic drugs alone control atrial flutter in only 50-60% of patients. 6, 7

Important caveat: When using class IC antiarrhythmic drugs (flecainide, propafenone), concomitant AV nodal blocking drugs must be administered to prevent rapid ventricular rates if flutter occurs. 1

Refractory cases:

• For patients with inadequate rate control despite pharmacological therapy, AV nodal ablation with permanent pacemaker implantation is recommended. 4, 3

Common Pitfalls and Clinical Pearls

• Rate control is more difficult to achieve in atrial flutter than in atrial fibrillation. 1, 2
• Conversion of atrial flutter to atrial fibrillation may occur with antiarrhythmic drugs. 1
• Atrial flutter and atrial fibrillation frequently coexist—22-50% of patients develop atrial fibrillation within 14-30 months after CTI ablation. 2
• Risk factors for developing atrial fibrillation after flutter ablation include prior atrial fibrillation, depressed left ventricular function, structural heart disease, and increased left atrial size. 2
• Patients should not be discharged within 12 hours of electrical or pharmacological conversion to normal sinus rhythm. 8