From the Guidelines
The treatment of new onset atrial flutter should begin with rate control using medications such as beta-blockers or calcium channel blockers, and anticoagulation should be initiated based on the patient's CHA₂DS₂-VASc score. For rate control, medications such as beta-blockers (e.g., metoprolol 25-100 mg twice daily) or calcium channel blockers (e.g., diltiazem 120-360 mg daily in divided doses) can be used 1. Some key points to consider in the management of atrial flutter include:
- Anticoagulation should be initiated based on the patient's CHA₂DS₂-VASc score, typically with direct oral anticoagulants like apixaban (5 mg twice daily) or warfarin (target INR 2-3) 1.
- For rhythm control, cardioversion is often recommended and can be performed electrically (synchronized DC cardioversion at 50-100 joules) or pharmacologically with agents like amiodarone (loading dose 400 mg three times daily for 1 week, then 200 mg daily) 1.
- If the flutter has been present for more than 48 hours, anticoagulation should be given for at least 3 weeks before cardioversion or a transesophageal echocardiogram should be performed to rule out atrial thrombi 1.
- For long-term management, catheter ablation of the cavotricuspid isthmus is highly effective with success rates exceeding 90% 1. It is also important to evaluate patients for underlying causes such as hyperthyroidism, alcohol use, or structural heart disease, as addressing these factors can prevent recurrence 1.
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. 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. Conversion of atrial flutter/ fibrillation usually (70% of those who converted) occurred within 30 minutes of the start of infusion and was dose related.
New Onset Atrial Flutter Treatment: Ibutilide fumarate can be used for the rapid conversion of atrial flutter of recent onset to sinus rhythm. The conversion rates for atrial flutter are 53% for 1 mg ibutilide fumarate and 70% for 2 mg ibutilide fumarate. Conversion usually occurs within 30 minutes of the start of infusion and is dose-related 2.
From the Research
Treatment Options for New Onset Atrial Flutter
- Cardioversion is a rhythm control strategy to restore normal/sinus rhythm, and can be achieved through drugs (pharmacological) or a synchronised electric shock (electrical cardioversion) 3.
- 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 (certainty of evidence: moderate) 4.
- All tested electrical cardioversion strategies for atrial flutter had very high efficacy (97.9% to 100%) 4.
Pharmacological Treatment
- Diltiazem (calcium channel blocker) and metoprolol (beta-blocker) are both commonly used to treat atrial fibrillation/flutter (AFF) in the emergency department (ED) 5.
- Diltiazem was more effective in achieving rate control in ED patients with AFF and did so with no increased incidence of adverse effects 5.
- IV diltiazem treatment was significantly more successful in rate control for AF with rapid ventricular response (RVR) than IV metoprolol 6.
- Metoprolol was associated with a 26% lower risk of adverse events (total incidence 10%) compared to diltiazem (total incidence 19%) 7.
Electrical Cardioversion
- Electrical cardioversion is a widely used treatment for atrial fibrillation and atrial flutter 3.
- The efficacy and safety of electrical cardioversion for atrial fibrillation, atrial flutter, and atrial tachycardias have been assessed in a network meta-analysis 4.
- The rate of mortality and stroke or systemic embolism at 30 days was extremely low after electrical cardioversion for atrial flutter 4.