From the Guidelines
Management of atrial flutter should prioritize a combination of rate control, rhythm control, and anticoagulation therapy, with catheter ablation considered for recurrent episodes or when medications are ineffective or poorly tolerated, as recommended by the 2015 ACC/AHA/HRS guideline 1.
Key Considerations
- Initial treatment focuses on controlling ventricular rate using AV nodal blocking agents such as beta-blockers, calcium channel blockers, or digoxin.
- For rhythm control, cardioversion is often effective, using either synchronized electrical cardioversion or pharmacological cardioversion with antiarrhythmic drugs like amiodarone or flecainide.
- Anticoagulation is essential for patients with risk factors for thromboembolism, typically with direct oral anticoagulants (DOACs) like apixaban or warfarin.
Long-term Management
- Catheter ablation is highly effective, particularly for typical cavotricuspid isthmus-dependent flutter, with success rates exceeding 90% 1.
- Ablation should be considered for recurrent episodes or when medications are ineffective or poorly tolerated.
- Post-procedure, anticoagulation should continue based on the patient's CHA₂DS₂-VASc score, not the presence of the arrhythmia itself.
Additional Recommendations
- Ongoing management with antithrombotic therapy is recommended in patients with atrial flutter to align with recommended antithrombotic therapy for patients with AF 1.
- Assessment of associated hemodynamic abnormalities for potential repair of structural defects is recommended in ACHD patients as part of therapy for SVT 1.
From the Research
Management of Atrial Flutter
- Atrial flutter is a macroreentrant arrhythmia that is associated with cardiovascular and pulmonary disease, with 200,000 new cases expected to develop every year in the United States 2.
- The most common form of atrial flutter involves a large reentrant circuit within the right atrium, encircling the tricuspid annulus, and treatment often involves electrical cardioversion and/or antiarrhythmic medications 2.
- Type I and Type III antiarrhythmic drugs are often 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 2.
Treatment Options
- Radiofrequency catheter ablation has been used to interrupt the reentrant circuit and prevent recurrences of atrial flutter, with an acute success rate of over 90% 2.
- Diltiazem (calcium channel blocker) and metoprolol (beta-blocker) are both commonly used to treat atrial fibrillation/flutter, with diltiazem being more effective in achieving rate control in ED patients with AFF 3.
- However, in ED patients with complex atrial fibrillation or flutter, attempts at rate and rhythm control are associated with a nearly 6-fold higher adverse event rate than that for patients who are not managed with rate or rhythm control 4.
Rate Control
- Beta-blockers (BBs) and nondihydropyridine calcium channel blockers (CCBs) are used for rate control in ED patients with atrial fibrillation, with CCBs being used more frequently than BBs 5.
- Predictors of BB versus CCB use include prior use of a BB, being sent in from a doctor's office, or being seen at a teaching hospital, while patients with evidence of heart failure or prior use of a CCB are less likely to receive a BB 5.
- Among propensity score-matched patients with no rhythm control attempts, use of a BB for rate control was associated with a lower rate of hospitalization compared to CCBs 5.
Pathway for Management
- A novel pathway for the management of atrial fibrillation and atrial flutter has been developed, with the acronym RACE, which reflects the 4 main components in patient management: rate control, anticoagulation therapy, cardioversion, and electrophysiology/antiarrhythmic medication 6.