What is the management of atrial flutter with rapid ventricular response (tachycardia)?

From the Guidelines

Management of atrial flutter with rapid ventricular response requires immediate rate control followed by rhythm control strategies, with a focus on reducing morbidity, mortality, and improving quality of life. Initially, administer AV nodal blocking agents such as intravenous diltiazem (0.25 mg/kg over 2 minutes, followed by infusion at 5-15 mg/hour) or metoprolol (5 mg IV over 2-5 minutes, repeated up to 3 doses) as recommended by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1. For hemodynamically unstable patients, synchronized electrical cardioversion at 50-100 joules is indicated.

Rate Control Strategies

• AV nodal blocking agents such as beta blockers, diltiazem, or verapamil are useful to control the ventricular rate in patients with hemodynamically tolerated atrial flutter, as stated in the 2015 ACC/AHA/HRS guideline 1.
• Beta blockers, such as metoprolol, are preferred agents for achieving rate control unless otherwise contraindicated, as mentioned in the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1.

Rhythm Control Strategies

• Catheter ablation of the CTI is useful in patients with atrial flutter that is either symptomatic or refractory to pharmacological rate control, as recommended by the 2015 ACC/AHA/HRS guideline 1.
• Antiarrhythmic medications such as flecainide, propafenone, sotalol, or amiodarone may be considered to maintain sinus rhythm in patients with symptomatic, recurrent atrial flutter, as stated in the 2015 ACC/AHA/HRS guideline 1.

Anticoagulation

• Anticoagulation is essential with a CHA₂DS₂-VASc score ≥2 in men or ≥3 in women, typically with direct oral anticoagulants like apixaban 5 mg twice daily or warfarin with INR 2-3, as recommended by the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation 1.

Atrial flutter requires aggressive management because the organized atrial activity allows for more rapid AV nodal conduction than atrial fibrillation, often resulting in ventricular rates of 150 beats per minute (2:1 conduction) which can lead to tachycardia-induced cardiomyopathy if sustained.

From the FDA Drug Label

Diltiazem slows the ventricular rate in patients with a rapid ventricular response during atrial fibrillation or atrial flutter

• Diltiazem can be used to manage atrial flutter with rapid ventricular response by slowing the ventricular rate.
• The therapeutic benefits of diltiazem in supraventricular tachycardias are related to its ability to slow AV nodal conduction time and prolong AV nodal refractoriness 2.

From the Research

Management of Atrial Flutter with Rapid Ventricular Response

• Atrial flutter is a macroreentrant arrhythmia that is associated with cardiovascular and pulmonary disease, and its treatment often involves electrical cardioversion and/or antiarrhythmic medications 3.
• Type I and Type III antiarrhythmic drugs can be used to terminate or prevent recurrent episodes of atrial flutter, 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 has been used to interrupt the reentrant circuit and prevent recurrences of atrial flutter, with an acute success rate of over 90% 3.
• Atrioventricular node blocking agents, including beta-adrenergic blockers, non-dihydropyridine calcium channel blockers, and digoxin, are usually effective in controlling ventricular rate in atrial fibrillation and flutter 4.
• The choice of agent for rate control depends on the individual patient and clinical situation, with beta-blockers being preferable in patients with myocardial ischemia, myocardial infarction, and hyperthyroidism, and non-dihydropyridine calcium channel blockers being preferred in patients with bronchial asthma and chronic obstructive pulmonary disease 4.

Comparison of Agents for Rate Control

• Diltiazem may achieve rate control faster than metoprolol, although both agents seem safe and effective for rate control in patients with atrial fibrillation with rapid ventricular response 5.
• A systematic review of observational studies and randomized clinical trials found that high-level evidence is lacking to inform clinical decision making regarding effective and safe management of atrial fibrillation/atrial flutter with rapid ventricular response in patients with acute decompensated heart failure 6.
• The review found that diltiazem was effective in achieving therapeutic response in patients with atrial fibrillation/atrial flutter with rapid ventricular response, but worsening heart failure symptoms occurred more frequently in those receiving diltiazem compared to metoprolol 6.

Treatment Approaches

• Electrical cardioversion is the treatment of choice when the clinical condition is unstable or the patient is hemodynamically compromised 7, 4.
• Radiofrequency ablation of the AV node or anomalous tract may be considered in refractory or high-risk subjects as a last resort 7.
• Antiarrhythmic drugs alone control atrial flutter in only 50% to 60% of patients, and radiofrequency catheter ablation is a more effective treatment option for preventing recurrences of atrial flutter 3.