What is the treatment for atrial flutter?

From the Guidelines

The treatment of atrial flutter should focus on controlling heart rate, restoring normal rhythm, and preventing complications, with catheter ablation of the CTI being a highly effective definitive treatment, as recommended by the 2015 ACC/AHA/HRS guideline 1.

Key Considerations

• Initial management typically involves rate control with medications such as beta-blockers, calcium channel blockers, or digoxin.
• For rhythm control, electrical cardioversion is highly effective for acute conversion.
• Antiarrhythmic medications like amiodarone, flecainide, or propafenone may be used to maintain normal rhythm.
• Catheter ablation, particularly cavotricuspid isthmus ablation, offers a definitive treatment with success rates exceeding 90% 1.
• Anticoagulation therapy is crucial to prevent stroke, with the need based on stroke risk factors assessed by the CHA₂DS₂-VASc score 1.

Treatment Options

• Rate control: beta-blockers (metoprolol 25-100 mg twice daily), calcium channel blockers (diltiazem 120-360 mg daily), or digoxin (0.125-0.25 mg daily) 1.
• Rhythm control: electrical cardioversion (synchronized shock of 50-100 joules), antiarrhythmic medications like amiodarone (loading dose 400-600 mg daily for 2-4 weeks, then 200 mg daily) 1.
• Catheter ablation: particularly cavotricuspid isthmus ablation, with success rates exceeding 90% 1.
• Anticoagulation therapy: warfarin with INR 2-3, or direct oral anticoagulants like apixaban 5 mg twice daily 1.

Patient-Specific Considerations

• Symptom severity, flutter duration, underlying heart disease, and patient preferences should guide treatment choice 1.
• Atrial flutter requires treatment because its organized reentry circuit in the right atrium causes rapid ventricular rates that can lead to heart failure, stroke, or tachycardia-induced cardiomyopathy if left untreated 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. A review of the world literature revealed reports of 568 patients treated with oral flecainide acetate for paroxysmal atrial fibrillation/flutter (PAF). As with other Class I agents, patients treated with flecainide acetate for atrial flutter have been reported with 1:1 atrioventricular conduction due to slowing the atrial rate.

The treatment of atrial flutter may include propafenone or flecainide, which are indicated to prolong the time to recurrence of paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms 2 3.

• Concomitant treatment with drugs that increase the functional AV refractory period is recommended to prevent 1:1 conduction and increase in ventricular rate.
• Concomitant negative chronotropic therapy such as digoxin or beta-blockers may lower the risk of this complication 3.
• It is essential to use these medications with caution and consider the potential risks, including proarrhythmic effects 2 3.

From the Research

Treatment Options for Atrial Flutter

• Electrical cardioversion and/or antiarrhythmic medications are commonly used to treat atrial flutter 4
• 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 4
• Radiofrequency catheter ablation is a highly effective treatment option, with a success rate of over 90% in interrupting the reentrant circuit and preventing recurrences of atrial flutter 4, 5
• Catheter ablation is increasingly being used as a first-line treatment option for atrial flutter in certain patients 5

Rate Control vs. Rhythm Control

• Rate control treatment is simple and relatively easy, and can be achieved using pharmacological agents such as beta-blockers, non-dihydropyridine calcium channel blockers, and digoxin 6, 7
• Rhythm control therapy, on the other hand, aims to maintain sinus rhythm using antiarrhythmic medications or catheter ablation, and may be more effective in certain patients, such as those with tachycardia-induced cardiomyopathy 6, 8
• The choice between rate control and rhythm control depends on the individual patient's clinical situation and characteristics 6, 7, 8

Specific Treatment Strategies

• For patients with atrial fibrillation and heart failure, rate control may be a better initial treatment option, with rhythm control considered if symptoms persist 6
• In patients with tachycardia-induced cardiomyopathy and persistent atrial flutter, a rhythm control strategy using catheter ablation or electrical cardioversion may be more effective in achieving left ventricular function recovery 8
• Strict rate control, aiming for an average heart rate < 80 bpm, may be more effective than lenient rate control in achieving left ventricular function recovery in patients with tachycardia-induced cardiomyopathy and persistent atrial flutter 8