From the Guidelines
The most effective treatment for atrial flutter in the emergency department is synchronized cardioversion for hemodynamically unstable patients, and for stable patients, rate control can be achieved with intravenous or oral beta blockers, diltiazem, or verapamil, while rhythm control can be attempted with oral dofetilide or intravenous ibutilide.
Treatment Options
- For hemodynamically unstable patients, synchronized cardioversion is recommended as the first line of treatment 1.
- For stable patients, rate control can be achieved with:
- Intravenous or oral beta blockers, such as esmolol, which is generally the preferred intravenous beta blocker due to its rapid onset 1.
- Diltiazem, which is the preferred intravenous calcium channel blocker for acute rate control due to its safety and efficacy 1.
- Verapamil, which should be avoided in patients with advanced heart failure and in patients with heart block or sinus node dysfunction in the absence of pacemaker therapy 1.
- Rhythm control can be attempted with:
- Oral dofetilide, which is useful for acute pharmacological cardioversion in patients with atrial flutter 1.
- Intravenous ibutilide, which converts atrial flutter to sinus rhythm in approximately 60% of cases, but carries the risk of torsades de pointes, particularly in patients with reduced left ventricular ejection fraction 1.
Important Considerations
- Anticoagulation issues for chemical cardioversion are the same as those for electrical cardioversion of atrial flutter 1.
- Patients receiving ibutilide should undergo continuous ECG monitoring during administration and for at least 4 hours after completion of dosing, and pretreatment with magnesium can increase the efficacy and reduce the risk of torsades de pointes 1.
- Rapid atrial pacing is useful for acute conversion of atrial flutter in patients who have pacing wires in place as part of a permanent pacemaker or implantable cardioverter-defibrillator, or for temporary atrial pacing after cardiac surgery 1.
From the FDA Drug Label
Ibutilide fumarate injection produces dose-related prolongation of the QT interval, which is thought to be associated with its antiarrhythmic activity. Clinical Studies Treatment with intravenous ibutilide fumarate for acute termination of recent onset atrial flutter/fibrillation was evaluated in 466 patients participating in two randomized, double-blind, placebo-controlled clinical trials Among patients with atrial flutter, 53% receiving 1 mg ibutilide fumarate and 70% receiving 2 mg ibutilide fumarate converted, compared to 18% of those receiving sotalol
Treatment of Atrial Flutter in ED:
- Ibutilide fumarate injection can be used for the treatment of atrial flutter in the ED.
- The recommended dose is 1 mg iv over 10 minutes, which can be repeated after 10 minutes if necessary.
- Key Considerations:
- Patients should be monitored with continuous ECG for at least 4 hours after infusion.
- Hypokalemia and hypomagnesemia should be corrected before treatment.
- Skilled personnel and proper equipment should be available during and after administration.
- The risk of proarrhythmia, including torsades de pointes, should be anticipated and managed accordingly. 2
From the Research
Treatment Options for Atrial Flutter in the Emergency Department
- Diltiazem and metoprolol are commonly used to treat atrial fibrillation/flutter in the emergency department (ED) 3.
- A study comparing the effectiveness of diltiazem and metoprolol for rate control of atrial fibrillation/flutter in the ED found that diltiazem was more effective in achieving rate control with no increased incidence of adverse effects 3.
- Another study found that attempts at rate and rhythm control in ED patients with complex atrial fibrillation or flutter 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.
Cardioversion Strategies
- Electrocardioversion, chemical cardioversion, and spontaneous cardioversion are different management approaches for atrial flutter in the ED 5.
- A network meta-analysis found that anteroapical biphasic truncated exponential waveform cardioversion, quinidine, ibutilide, propafenone, amiodarone, and sotalol likely result in a large increase in maintenance of sinus rhythm at hospital discharge or end of study follow-up for paroxysmal atrial fibrillation 6.
- For atrial flutter, 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 6.
Safety and Efficacy of Ibutilide
- A retrospective cohort study found that ibutilide is effective and safe for cardioversion in atrial fibrillation and flutter in the community emergency department setting, with a cardioversion rate of 54.8% within 4 hours 7.
- The study also found that age, atrial flutter, and no history of atrial fibrillation and flutter are associated with cardioversion success 7.
Patient Outcomes
- A study found that patients with atrial flutter who undergo electrocardioversion have a higher success rate and lower admission rate compared to those treated with antiarrhythmic medications 5.
- Another study found that the majority of patients with atrial flutter are discharged home, and deaths are typically related to concurrent medical illness rather than atrial flutter 5.