What is the management of slow atrial flutter?

From the Guidelines

Slow atrial flutter should be managed with catheter ablation of the CTI as a first-line treatment for symptomatic or refractory patients, as recommended by the 2015 ACC/AHA/HRS guideline 1. This approach is based on the highest level of evidence (Class I, LOE B-R) and is supported by the American College of Cardiology, American Heart Association, and Heart Rhythm Society 1. For patients who are hemodynamically stable, rate control can be achieved with beta blockers, diltiazem, or verapamil 1. Some key points to consider in the management of slow atrial flutter include:

• Catheter ablation is useful in patients with recurrent symptomatic non-CTI-dependent flutter after failure of at least one antiarrhythmic agent 1
• Ongoing management with antithrombotic therapy is recommended in patients with atrial flutter to align with recommended antithrombotic therapy for patients with AF 1
• The choice of antiarrhythmic drugs, such as amiodarone, dofetilide, or sotalol, depends on underlying heart disease and comorbidities 1
• Catheter ablation may be considered as primary therapy for patients with recurrent symptomatic non-CTI-dependent flutter, after carefully weighing potential risks and benefits 1.

From the FDA Drug Label

In patients without structural heart disease, propafenone is indicated to prolong the time to recurrence of – paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms. As with other agents, some patients with atrial flutter treated with propafenone have developed 1:1 conduction, producing an increase in ventricular rate. Concomitant treatment with drugs that increase the functional AV refractory period is recommended.

Management of slow atrial flutter with propafenone (PO) involves using the drug to prolong the time to recurrence of paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms. However, it is crucial to note that:

• Propafenone may cause 1:1 conduction, leading to an increase in ventricular rate in some patients with atrial flutter.
• Concomitant treatment with drugs that increase the functional AV refractory period is recommended to mitigate this risk. It is essential to use propafenone with caution and consider the potential risks and benefits, especially since the drug has proarrhythmic effects 2.

From the Research

Management of Atrial Flutter

• Atrial flutter is a macroreentrant arrhythmia that can be managed with electrical cardioversion and/or antiarrhythmic medications 3.
• Type I and Type III antiarrhythmic drugs can be used to terminate or prevent recurrent episodes, while Type II (beta-blockers) and Type IV (calcium channel blockers) can be used to control the ventricular rate during atrial flutter 3.
• Radiofrequency catheter ablation is a highly effective treatment for atrial flutter, with a success rate of over 90% 3.

Rate Control Strategies

• Beta-blockers and non-dihydropyridine calcium channel blockers are effective in controlling ventricular rate in atrial fibrillation and flutter 4.
• Diltiazem (calcium channel blocker) has been shown to be more effective than metoprolol (beta-blocker) in achieving rate control in patients with atrial fibrillation or flutter 5.
• The choice of rate control agent depends on the individual patient's clinical situation, with beta-blockers preferred in patients with myocardial ischemia or hyperthyroidism, and non-dihydropyridine calcium channel blockers preferred in patients with bronchial asthma or chronic obstructive pulmonary disease 4.

Rhythm Control Strategies

• Rhythm control strategies may increase the risk of serious adverse events compared to rate control strategies 6.
• However, rhythm control strategies may be beneficial in patients with unbearable symptoms or those who are hemodynamically unstable due to atrial fibrillation or flutter 6.
• The decision to use a rhythm control strategy should be individualized based on the patient's specific clinical situation 6.

Special Considerations

• In patients with acute underlying medical illnesses, attempts at rate or rhythm control may be associated with a higher adverse event rate 7.
• In these patients, the benefits and risks of rate or rhythm control should be carefully weighed, and treatment should be individualized based on the patient's specific clinical situation 7.