From the Guidelines
Management of atrial flutter should prioritize catheter ablation of the cavotricuspid isthmus (CTI) for symptomatic or refractory patients, as it is a highly effective treatment with success rates exceeding 90% 1.
Key Considerations
- Rate control can be achieved with beta-blockers, calcium channel blockers, or digoxin, with the goal of maintaining a ventricular rate < 110 bpm 1.
- Rhythm control options include electrical cardioversion or pharmacological cardioversion with agents like amiodarone, with careful consideration of the patient's underlying cardiac conditions and comorbidities 1.
- Anticoagulation is essential for patients with risk factors, typically with direct oral anticoagulants or warfarin, to reduce the risk of stroke 1.
Treatment Options
- Catheter ablation of the CTI is recommended for patients with symptomatic or refractory atrial flutter, as well as those with recurrent symptomatic non-CTI-dependent flutter after failure of at least one antiarrhythmic agent 1.
- Antiarrhythmic drugs, such as amiodarone, dofetilide, or sotalol, may be considered for patients who are not candidates for catheter ablation or have contraindications to the procedure 1.
- Flecainide or propafenone may be considered for patients without structural heart disease or ischemic heart disease who have symptomatic recurrent atrial flutter, but with caution due to the risk of 1:1 conduction 1.
Long-term Management
- Catheter ablation may be reasonable for asymptomatic patients with recurrent atrial flutter, as it can avoid potential development of tachycardia-mediated cardiomyopathy and improve quality of life 1.
- Ongoing management with antithrombotic therapy is recommended for patients with atrial flutter, aligning with recommended antithrombotic therapy for patients with atrial fibrillation 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 Atrial Flutter: Propafenone can be used to prolong the time to recurrence of paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms. However, it may cause 1:1 conduction, leading to an increase in ventricular rate, and therefore, concomitant treatment with drugs that increase the functional AV refractory period is recommended 2.
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 3.
- 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 3.
- 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 3.
Treatment Options
- Radiofrequency catheter ablation has been used to interrupt the reentrant circuit and prevent recurrences of atrial flutter, with a success rate of over 90% 3, 4.
- Catheter ablation is an effective treatment option in certain patients that have atrial flutter refractory to medical management, and can improve quality of life assessments 4, 5.
- Anti-coagulation therapy is essential in patients with atrial flutter, especially those with a high risk of thromboembolic complications 5.
Ventricular Rate Control
- 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 6.
- Beta-blockers are preferable in patients with myocardial ischemia, myocardial infarction, and hyperthyroidism, while non-dihydropyridine calcium channel blockers are preferred in patients with bronchial asthma and chronic obstructive pulmonary disease 6.
- A comparison of rate control efficacy between beta-blockers and calcium channel blockers in patients hospitalized with atrial fibrillation found that beta-blockers were more potent for rapid reduction of the heart rate and demonstrated better efficiency in shortening the duration of hospitalization in a subgroup of patients 7.