From the Guidelines
The next best step for a patient in atrial flutter with a heart rate of 135 bpm who is currently on an amino drip and oral diltiazem every 6 hours would be to attempt vagal maneuvers, such as the Valsalva maneuver or carotid sinus massage, as recommended by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1.
Rationale
- The patient is currently hemodynamically stable, as evidenced by the lack of mention of any unstable symptoms, and therefore does not require immediate synchronized cardioversion.
- Vagal maneuvers are a recommended first-line intervention for terminating supraventricular tachycardia, including atrial flutter, and can be performed quickly and safely 1.
- The use of vagal maneuvers may help to terminate the arrhythmia and restore normal sinus rhythm, thereby improving the patient's symptoms and reducing the risk of tachycardia-induced cardiomyopathy.
Considerations
- If vagal maneuvers are unsuccessful, adenosine may be considered as a therapeutic and diagnostic agent to help terminate the arrhythmia and unmask atrial activity 1.
- The patient's current medication regimen, including oral diltiazem, may need to be adjusted or optimized to achieve adequate rate control, and the addition of a beta-blocker may be considered if not contraindicated.
- It is also important to evaluate for any precipitating factors, such as electrolyte abnormalities, thyroid dysfunction, or infection, that may be contributing to the patient's arrhythmia.
From the Research
Patient Assessment
- The patient is in a flutter with a heart rate (HR) of 135 beats per minute (bpm) and is currently on an amino drip and diltiazem (Dilt) PO q6h.
- The goal is to achieve rate control and determine the next best step in management.
Current Management
- The patient is already receiving diltiazem, a calcium channel blocker, which is commonly used for rate control in atrial fibrillation/flutter [(2,3,4)].
- The use of diltiazem has been shown to be effective in achieving rate control, with some studies suggesting it may be more effective than metoprolol, a beta-blocker [(2,3)].
Alternative Management Options
- Metoprolol, a beta-blocker, is also commonly used for rate control in atrial fibrillation/flutter [(2,3,4,5)].
- Some studies suggest that metoprolol may be associated with a lower risk of adverse events, such as hypotension and bradycardia, compared to diltiazem 4.
- Ibutilide, an antiarrhythmic medication, may also be considered for cardioversion in atrial fibrillation and flutter 6.
Next Best Step
- Consider continuing or adjusting the current diltiazem regimen to achieve optimal rate control [(2,3)].
- Alternatively, consider switching to metoprolol or adding metoprolol to the current regimen if the patient is not responding to diltiazem or is experiencing adverse events [(4,5)].
- Ibutilide may be considered if cardioversion is the goal, but its use should be carefully evaluated based on the patient's individual characteristics and medical history 6.