What is the emergency room (ER) treatment for atrial flutter?

From the Guidelines

Atrial flutter in the emergency room should be managed with initial rate control using medications like diltiazem or metoprolol, and for hemodynamically unstable patients, immediate synchronized electrical cardioversion is indicated. For rate control, medications such as diltiazem (initial IV bolus of 0.25 mg/kg over 2 minutes, followed by continuous infusion at 5-15 mg/hour) or metoprolol (5 mg IV over 2-5 minutes, repeated up to 3 doses) can be used 1. If the patient is stable with recent-onset flutter (less than 48 hours), chemical cardioversion may be attempted with ibutilide (1 mg IV over 10 minutes, may repeat once after 10 minutes) or procainamide (loading dose of 15-18 mg/kg IV at 20-50 mg/min) 1. Anticoagulation should be initiated unless contraindicated, typically with heparin (80 units/kg bolus followed by 18 units/kg/hour infusion) or direct oral anticoagulants, as the risk of stroke associated with atrial flutter is mitigated by anticoagulation 1. Some key points to consider in the management of atrial flutter include:

• The use of antithrombotic therapy to align with recommended antithrombotic therapy for patients with AF 1
• The potential risks and benefits of chemical cardioversion, including the risk of torsades de pointes with ibutilide 1
• The importance of identifying and addressing the underlying cause of atrial flutter, such as hyperthyroidism, pulmonary embolism, or electrolyte abnormalities 1
• The role of catheter ablation in the management of atrial flutter, particularly for patients with recurrent symptomatic atrial flutter 1 Overall, the management of atrial flutter in the emergency room requires a comprehensive approach that takes into account the patient's hemodynamic stability, the presence of underlying conditions, and the potential risks and benefits of different treatment options.

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. In a third double-blind study, 319 patients with atrial fibrillation or atrial flutter of 3 hours to 45 days duration were randomized to receive single, 10-minute intravenous infusions of either sotalol (1.5 mg/kg) or ibutilide fumarate injection (1 mg or 2 mg). 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

• Atrial Flutter ER Treatment: Ibutilide fumarate injection can be used for the treatment of atrial flutter.
• Conversion Rates: The conversion rates for atrial flutter were 53% for 1 mg ibutilide fumarate and 70% for 2 mg ibutilide fumarate.
• Key Considerations: Ibutilide can induce or worsen ventricular arrhythmias, and skilled personnel and proper equipment should be available during and after administration 2.
• Monitoring: Patients should be observed with continuous ECG monitoring for at least 4 hours following infusion or until QTc has returned to baseline 2.

From the Research

Atrial Flutter ER Treatment

• Atrial flutter is a macroreentrant arrhythmia that can be treated with electrical cardioversion and/or antiarrhythmic medications 3.
• 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 3.
• Radiofrequency catheter ablation is a highly effective treatment option for atrial flutter, with a success rate of over 90% 3, 4.

Ventricular Rate Control

• Atrioventricular node blocking agents, including beta-adrenergic blockers, non-dihydropyridine calcium channel blockers, and digoxin, can be used to control ventricular rate in atrial fibrillation and flutter 5.
• Diltiazem (calcium channel blocker) and metoprolol (beta-blocker) are commonly used to treat atrial fibrillation/flutter in the emergency department, with diltiazem being more effective in achieving rate control 6.
• However, in patients with acute underlying medical illnesses, attempts to control rate or rhythm may not be beneficial and may even be associated with a higher adverse event rate 7.

Treatment Options

• Electrical cardioversion is a treatment option for atrial flutter, especially in patients who are hemodynamically unstable 5.
• Catheter ablation, including radiofrequency catheter ablation and cryo catheter ablation, is a highly effective treatment option for atrial flutter and is increasingly being used as a first-line treatment option 4.
• Pharmacological therapy, including antiarrhythmic medications and atrioventricular node blocking agents, can also be used to treat atrial flutter 3, 5.