What medication should be given to a patient in atrial flutter who requires a rapid response?

From the Guidelines

For a patient in atrial flutter during a rapid response situation, intravenous ibutilide is the preferred medication for acute pharmacological cardioversion, as recommended by the 2015 ACC/AHA/HRS guideline 1. When considering medication options, the goal is to either convert the atrial flutter to a normal sinus rhythm or control the ventricular rate.

• For acute pharmacological cardioversion, intravenous ibutilide is recommended due to its efficacy in converting atrial flutter to sinus rhythm, as stated in the guideline 1.
• Alternatively, oral dofetilide can also be considered for acute pharmacological cardioversion, but intravenous ibutilide may be more suitable in a rapid response situation due to its faster onset of action.
• For patients who are hemodynamically stable, intravenous or oral beta blockers, diltiazem, or verapamil can be used for acute rate control, as these medications can effectively slow the ventricular response rate without converting the atrial flutter to sinus rhythm 1.
• In cases where the patient is hemodynamically unstable, synchronized cardioversion is the recommended treatment, as it can quickly restore a normal heart rhythm and improve cardiac output 1.
• It's also important to consider the patient's underlying cardiac function, blood pressure, and other comorbidities when selecting a medication, as certain medications may be contraindicated or require caution in specific patient populations.

From the FDA Drug Label

Ibutilide fumarate injection is indicated for the rapid conversion of atrial fibrillation or atrial flutter of recent onset to sinus rhythm. For a rapid response patient in atrial flutter, the medication to give is ibutilide (IV), as it is indicated for the rapid conversion of atrial flutter to sinus rhythm 2, 2.

• The conversion rates for ibutilide in patients with atrial flutter are:
  • 56% for 0.25 mg ibutilide fumarate
  • 61% for 0.5 mg ibutilide fumarate
  • 78% for 1 mg ibutilide fumarate 2.
• The majority of patients (53% and 72% in the 0.5 mg and 1 mg dose groups, respectively) converted to sinus rhythm remained in sinus rhythm for 24 hours 2.

From the Research

Medication Options for Rapid Response Patient in Atrial Flutter

• 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 3.
• Intravenous beta-blockers and non-dihydropyridine calcium channel blockers are equally effective in rapidly controlling the ventricular rate 3.
• Diltiazem (calcium channel blocker) was found to be more effective than metoprolol (beta-blocker) in achieving rate control in patients with atrial fibrillation or flutter in the emergency department 4, 5.
• The choice of medication depends on the individual patient's clinical situation, with beta-blockers being preferable in patients with myocardial ischemia, myocardial infarction, and hyperthyroidism, but should be avoided in patients with bronchial asthma and chronic obstructive pulmonary disease 3.
• Super-selective beta-1 blockers were found to be superior to conventional selective beta-1 blockers for target heart rate reduction in patients with acute atrial fibrillation and flutter 6.

Specific Medications

• Beta-blockers: metoprolol, esmolol, and landiolol are examples of beta-blockers that can be used for rate control in atrial fibrillation and flutter 3, 6, 5.
• Non-dihydropyridine calcium channel blockers: diltiazem and verapamil are examples of non-dihydropyridine calcium channel blockers that can be used for rate control in atrial fibrillation and flutter 3, 4, 5.
• Digoxin: can be used for rate control in atrial fibrillation and flutter, but is generally less effective in the acute setting 3.

Considerations

• The agent of first choice is usually individualized depending on the clinical situation 3.
• Factors precipitating rapid ventricular rate should be treated as well 3.
• When the clinical condition is unstable or the patient is hemodynamically compromised, immediate electrical cardioversion is the treatment of choice 3.