What is the treatment for atrial (a) flutter?

Treatment for Atrial Flutter

For hemodynamically unstable patients with atrial flutter, perform immediate synchronized cardioversion; for stable patients, initiate rate control with intravenous or oral beta blockers, diltiazem, or verapamil, followed by consideration of catheter ablation as the definitive long-term treatment. 1, 2

Acute Management Based on Hemodynamic Status

Hemodynamically Unstable Patients

• Immediate synchronized cardioversion is mandatory without delay in patients showing signs of hemodynamic compromise (hypotension, acute heart failure, ongoing chest pain, altered mental status) 3, 1, 4
• Atrial flutter cardioverts at lower energy levels than atrial fibrillation, making electrical cardioversion highly effective 1, 4
• Address anticoagulation considerations prior to cardioversion when time permits, though hemodynamic instability takes priority 1, 4

Hemodynamically Stable Patients

Rate Control Strategy (First-Line for Stable Patients)

• Beta blockers (intravenous or oral), diltiazem, or verapamil are the recommended first-line agents for acute rate control 3, 1, 2
• Intravenous diltiazem is the preferred calcium channel blocker due to its superior safety and efficacy profile 1, 4
• Esmolol is the preferred intravenous beta blocker because of its rapid onset and short half-life 4
• Rate control is more challenging in atrial flutter than atrial fibrillation due to less concealed AV nodal conduction, often requiring higher medication doses 2, 4
• Target resting heart rate <100 beats per minute 5

Critical contraindications for rate control agents:

• Avoid diltiazem and verapamil in patients with advanced heart failure, heart block, or sinus node dysfunction without pacemaker 1, 4
• Never use beta blockers, diltiazem, or verapamil in patients with pre-excited atrial flutter (Wolff-Parkinson-White syndrome), as this can precipitate ventricular fibrillation 3, 2
• For patients with systolic heart failure where beta blockers are contraindicated or ineffective, intravenous amiodarone can be used for acute rate control 3, 1, 2

Rhythm Control Strategy

Pharmacological cardioversion options:

• Oral dofetilide or intravenous ibutilide are effective for acute pharmacological cardioversion (approximately 60% success rate with ibutilide) 3, 1, 4, 6
• Monitor closely for QT prolongation and torsades de pointes when using ibutilide, especially in patients with reduced left ventricular ejection fraction 1
• Elective synchronized cardioversion is indicated in stable patients when pursuing rhythm control 3, 1, 4

Alternative rhythm control methods:

• Rapid atrial pacing is highly effective for acute conversion in patients with existing pacing wires (permanent pacemaker, ICD, or temporary post-cardiac surgery wires) 3, 1, 4

Anticoagulation Management

Atrial flutter carries the same stroke risk as atrial fibrillation (approximately 3% annually), requiring identical anticoagulation protocols 1, 2, 4

Timing-Based Anticoagulation Protocol

• For atrial flutter <48 hours duration in low-risk patients: Start anticoagulation before or immediately after cardioversion 2
• For atrial flutter ≥48 hours or unknown duration: Either provide therapeutic anticoagulation for 3 weeks before cardioversion OR perform transesophageal echocardiogram to exclude left atrial thrombus 2, 4
• Post-cardioversion: Continue anticoagulation for at least 4 weeks regardless of duration 2
• Long-term anticoagulation: Base decisions on thromboembolic risk profile using the same criteria as atrial fibrillation (CHA₂DS₂-VASc score) 2

Long-Term Management

Catheter Ablation (Preferred Definitive Treatment)

• Catheter ablation of the cavotricuspid isthmus (CTI) is the most effective long-term treatment with >90% success rate for typical atrial flutter 3, 2, 6, 7
• Catheter ablation is recommended for patients with symptomatic atrial flutter that is either refractory to pharmacological rate control or recurrent 3
• Ablation is reasonable as primary therapy for recurrent symptomatic non-CTI-dependent flutter before antiarrhythmic drug trials, after weighing risks and benefits 3, 2
• Consider ablation in patients undergoing AF ablation who also have documented CTI-dependent atrial flutter 3

Important consideration: 22-50% of patients develop atrial fibrillation within 14-30 months after CTI ablation 3, 4

• Risk factors for post-ablation AF include: prior AF, depressed left ventricular function, structural heart disease, ischemic heart disease, and increased left atrial size 3, 4

Antiarrhythmic Drug Therapy (When Ablation Not Pursued)

For patients with normal hearts (no structural heart disease):

• Flecainide or propafenone may be considered for maintaining sinus rhythm 3, 8, 9
• Critical warning: When using class IC agents (flecainide, propafenone), always coadminister AV nodal blocking drugs to prevent 1:1 AV conduction during atrial flutter, which can cause dangerously rapid ventricular rates 3, 8, 9
• Flecainide and propafenone are contraindicated in patients with structural heart disease or ischemic heart disease due to increased mortality risk 8, 9

For patients with structural heart disease:

• Amiodarone, dofetilide, or sotalol can maintain sinus rhythm 3, 2
• In patients with left ventricular ejection fraction >35%: dronedarone, sotalol, or amiodarone 5
• In patients with left ventricular ejection fraction <35%: amiodarone is the only recommended drug 5

Ongoing rate control if rhythm control not pursued:

• Beta blockers, diltiazem, or verapamil for chronic rate control 3
• Digoxin is not recommended as monotherapy for rate control in active patients 5
• Digoxin and dronedarone may be used in combination with other agents to optimize rate control 5

Critical Pitfalls to Avoid

• Failing to recognize hemodynamic instability requiring immediate cardioversion rather than attempting rate control 1
• Using verapamil, diltiazem, or beta blockers in pre-excited atrial flutter (can precipitate ventricular fibrillation) 3, 1, 2
• Underestimating stroke risk in atrial flutter patients—treat anticoagulation identically to atrial fibrillation 1, 2
• Using class IC agents without concomitant AV nodal blockade, risking 1:1 AV conduction and rapid ventricular rates 3, 2, 8, 9
• Inadequate monitoring for QT prolongation when using ibutilide for pharmacological cardioversion 1
• Expecting easy rate control—atrial flutter is paradoxically more difficult to rate-control than atrial fibrillation 1, 2, 4
• Using class IC agents in patients with structural heart disease or prior myocardial infarction due to increased mortality risk demonstrated in the CAST trial 9