What is the treatment for atrial flutter with tachycardia?

Treatment of Atrial Flutter with Heart Rate 140

For hemodynamically stable atrial flutter with a ventricular rate of 140 bpm, initiate intravenous beta blockers (esmolol preferred) or diltiazem for immediate rate control, with catheter ablation as the definitive long-term treatment. 1, 2

Immediate Assessment

First, determine hemodynamic stability. A heart rate of 140 bpm with atrial flutter can be hemodynamically tolerated in many patients, but assess for signs of instability including hypotension, altered mental status, chest pain, or acute heart failure. 2, 3

• If the patient is hemodynamically unstable, proceed immediately to synchronized electrical cardioversion starting at 50-100J (atrial flutter responds to lower energy than atrial fibrillation). 2, 3
• If hemodynamically stable, proceed with pharmacological rate control as outlined below. 1, 2

Acute Rate Control Strategy

For hemodynamically stable patients, rate control is the initial priority:

First-Line Agents

• Intravenous esmolol is the preferred beta blocker due to its rapid onset and short half-life, allowing for quick titration. 2
• Intravenous diltiazem is the preferred calcium channel blocker due to its favorable safety and efficacy profile. 2
• Beta blockers, diltiazem, or verapamil are all Class I recommendations for rate control in hemodynamically tolerated atrial flutter. 1

Important Considerations for Drug Selection

• Beta blockers are generally preferred in patients with heart failure or myocardial ischemia. 1, 4
• Avoid diltiazem and verapamil in patients with advanced heart failure, heart block, or sinus node dysfunction without pacemaker therapy. 2
• Absolutely avoid beta blockers, diltiazem, and verapamil in pre-excited atrial flutter (Wolff-Parkinson-White syndrome) due to risk of accelerated ventricular rates degenerating to ventricular fibrillation. 1, 2

Alternative Agent

• Intravenous amiodarone can be used for acute rate control in patients with systolic heart failure where beta blockers are contraindicated or ineffective, though it should not be used for long-term rate control due to toxicity concerns. 1, 2

Critical Pitfall to Avoid

Rate control is often MORE difficult to achieve in atrial flutter than atrial fibrillation because the relatively slower atrial rate (typically 250-300 bpm) paradoxically results in more rapid AV nodal conduction due to less concealed AV nodal conduction. 1, 2 Therefore:

• Higher doses of rate-control agents are frequently required. 1
• Combination therapy with multiple agents may be necessary to achieve adequate rate control. 1

Anticoagulation

Initiate antithrombotic therapy following the same guidelines as atrial fibrillation. 1, 2

• The annual stroke risk in atrial flutter is approximately 3%, similar to atrial fibrillation. 2
• If cardioversion is planned and atrial flutter duration is ≥48 hours or unknown, appropriate anticoagulation must be addressed before cardioversion. 2, 3, 5

Definitive Long-Term Management

Catheter ablation of the cavotricuspid isthmus (CTI) is the preferred definitive treatment for symptomatic atrial flutter or flutter refractory to pharmacological rate control (Class I recommendation). 1, 2

Why Ablation is Preferred

• Ablation success rates exceed 90% for typical CTI-dependent atrial flutter. 6
• Rate control with medications alone is often difficult to maintain long-term. 1, 2
• Ablation prevents development of tachycardia-mediated cardiomyopathy. 2

If Ablation is Not Pursued

• Beta blockers, diltiazem, or verapamil can be used for long-term rate control, often requiring higher doses or combination therapy. 1, 2
• For rhythm control, amiodarone, dofetilide, or sotalol can maintain sinus rhythm in symptomatic recurrent atrial flutter (Class IIa recommendation). 1, 2
• Flecainide or propafenone may be considered ONLY in patients without structural heart disease due to proarrhythmic risk. 2, 7, 8

Additional Long-Term Consideration

Be aware that 22-50% of patients develop atrial fibrillation within 14-30 months after CTI ablation for atrial flutter, particularly those with prior atrial fibrillation, depressed left ventricular function, structural heart disease, or increased left atrial size. 2, 3