From the Guidelines
The initial workup for a patient with new onset atrial flutter who responded to IV metoprolol should include a comprehensive cardiac evaluation, starting with a 12-lead ECG, laboratory tests, and an echocardiogram, as well as assessment of stroke risk using the CHA₂DS₂-VASc score, as recommended by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1.
Initial Evaluation
The evaluation should include:
- A 12-lead ECG to document the rhythm and assess for any other abnormalities
- Laboratory tests, such as complete blood count, comprehensive metabolic panel, thyroid function tests, and cardiac biomarkers, to identify potential triggers or comorbidities
- An echocardiogram to evaluate cardiac structure and function, looking for valvular disease, chamber enlargement, or reduced ejection fraction
- A chest X-ray to identify pulmonary pathology that could contribute to the arrhythmia
Stroke Risk Assessment
Assessment of stroke risk using the CHA₂DS₂-VASc score is crucial to determine the need for anticoagulation therapy, as recommended by the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1.
Ongoing Management
For ongoing management, consider oral rate control medications, such as metoprolol 25-100 mg twice daily or diltiazem 120-360 mg daily in divided doses, as recommended by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1. Anticoagulation should be initiated if the CHA₂DS₂-VASc score is ≥1 in men or ≥2 in women, typically with a direct oral anticoagulant like apixaban 5 mg twice daily.
Key Considerations
- Atrial flutter often indicates underlying cardiac disease or systemic issues that require identification and management to prevent recurrence and complications
- The choice of rate control medication and anticoagulation therapy should be individualized based on the patient's underlying conditions and risk factors
- The 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia provides recommendations for the acute treatment of atrial flutter, including pharmacological cardioversion, rate control, and synchronized cardioversion 1.
From the Research
Initial Workup for Atrial Flutter
For a patient with new onset atrial flutter that responded to Ivy Metropol, the initial workup should include:
- Evaluation of the patient's comorbidity profile 2
- Assessment of the antiarrhythmic drug onset of action and side effect profile 2
- Consideration of the need for a physician with experience in sedation, or anaesthetics support for electrical cardioversion 2
- Investigation into the underlying cause of the atrial flutter, as it is essential to identify and address any reversible causes 2
Key Aspects to Consider
When choosing the cardioversion method, the following key aspects should be considered:
- The efficacy and safety of pharmacological and electrical cardioversion for atrial flutter 2
- The results of the network meta-analysis, which showed that ibutilide, propafenone, dofetilide, and sotalol probably result in a large increase in the maintenance of sinus rhythm at hospital discharge or end of study follow-up 2
- The extremely low rate of mortality and stroke or systemic embolism at 30 days, as well as the high efficacy of electrical cardioversion strategies for atrial flutter 2