From the Guidelines
Atrial flutter should be managed with a focus on rate control, rhythm control, and anticoagulation to reduce the risk of stroke and improve quality of life, as recommended by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1.
Key Considerations
- Atrial flutter is a cardiac arrhythmia characterized by rapid, regular atrial contractions at a rate of 250-350 beats per minute.
- Treatment depends on the patient's stability and symptoms.
- For acute management in unstable patients, immediate synchronized electrical cardioversion at 50-100 joules is recommended.
- For stable patients, rate control with medications like beta-blockers (metoprolol 5mg IV, followed by oral dosing) or calcium channel blockers (diltiazem 0.25 mg/kg IV over 2 minutes) is appropriate, followed by rhythm control strategies.
- Anticoagulation should be initiated based on stroke risk using the CHA₂DS₂-VASc score, typically with direct oral anticoagulants like apixaban 5mg twice daily or warfarin with a target INR of 2-3.
- Long-term management includes catheter ablation for recurrent or symptomatic flutter, which has a high success rate of 90-95% for typical flutter.
Management Strategies
- Catheter ablation is recommended for patients with symptomatic, recurrent atrial flutter, with a high success rate of 90-95% for typical flutter 1.
- Anticoagulation should be initiated based on stroke risk using the CHA₂DS₂-VASc score, with direct oral anticoagulants like apixaban 5mg twice daily or warfarin with a target INR of 2-3 1.
- Rate control with medications like beta-blockers or calcium channel blockers is appropriate for stable patients, followed by rhythm control strategies 1.
- Rhythm control strategies, including catheter ablation and antiarrhythmic medications, should be considered for patients with symptomatic, recurrent atrial flutter 1.
Important Considerations
- Atrial flutter can lead to tachycardia-induced cardiomyopathy, stroke, or progression to atrial fibrillation if left untreated.
- The risk of stroke associated with atrial flutter is similar to that of atrial fibrillation, and anticoagulation should be initiated accordingly 1.
- Catheter ablation is a highly effective treatment option for recurrent or symptomatic atrial flutter, with a high success rate and low risk of complications 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.
Atrial Flutter Treatment: Propafenone is indicated 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 concomitant treatment with drugs that increase the functional AV refractory period is recommended 2.
A review of the world literature revealed reports of 568 patients treated with oral flecainide acetate for paroxysmal atrial fibrillation/flutter (PAF). Ventricular tachycardia was experienced in 0.4% (2/568) of these patients. As with other Class I agents, patients treated with flecainide acetate for atrial flutter have been reported with 1:1 atrioventricular conduction due to slowing the atrial rate.
Key Considerations:
- Flecainide may cause ventricular pro-arrhythmic effects in patients with atrial fibrillation/flutter, including increased PVCs, VT, ventricular fibrillation (VF), and death 3.
- Concomitant negative chronotropic therapy, such as digoxin or beta-blockers, may lower the risk of 1:1 atrioventricular conduction 3.
From the Research
Definition and Prevalence of Atrial Flutter
- Atrial flutter is a macroreentrant arrhythmia associated with cardiovascular and pulmonary disease 4
- It is estimated that 200,000 new cases of atrial flutter develop every year in the United States, with a male to female ratio of over 2:1 4
- Atrial flutter is often associated with atrial fibrillation, and the two conditions share similar risk factors and complications 4, 5
Treatment Options for Atrial Flutter
- Treatment options for atrial flutter include electrical cardioversion, antiarrhythmic medications, and catheter ablation 4, 6
- Type I and Type III antiarrhythmic drugs are often used to terminate or prevent recurrent episodes of atrial flutter, while Type II (beta-blockers) and Type IV (calcium channel blockers) can be used to control the ventricular rate 4
- Radiofrequency catheter ablation is a highly effective treatment option for atrial flutter, with a success rate of over 90% in some studies 4, 6
Management of Atrial Flutter in Specific Patient Populations
- In patients with acute underlying medical illnesses, attempts to control rate or rhythm may not be beneficial and may even be associated with adverse events 7
- In patients with atrial fibrillation or flutter and an acute underlying medical illness, the primary goal of treatment should be to stabilize the patient and address the underlying condition, rather than attempting to control the arrhythmia 7
- In patients with atrial fibrillation or flutter and Wolff-Parkinson-White syndrome, beta-blockers, calcium channel blockers, and digoxin should be avoided, as they can precipitate ventricular fibrillation 8
Acute Ventricular Rate Control 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 8
- The choice of agent for acute ventricular rate control should be individualized based on the clinical situation, with beta-blockers preferred in patients with myocardial ischemia, myocardial infarction, and hyperthyroidism, and non-dihydropyridine calcium channel blockers preferred in patients with bronchial asthma and chronic obstructive pulmonary disease 8