View source for Supraventricular tachycardia AHA recommendations for Management of Atrial Flutter

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{{Supraventricular tachycardia}}
{{CMG}} {{AE}}{{AA}}
==Overview==
Oral [[dofetilide]] or intravenous [[ibutilide]] is useful for acute pharmacological cardioversion in patients with atrial flutter. Intravenous or oral [[beta blockers]], [[diltiazem]], or [[verapamil]] are useful for acute rate control in patients with atrial flutter who are hemodynamically stable. Elective [[synchronized cardioversion]] is indicated in stable patients with well-tolerated atrial flutter when a rhythm-control strategy is pursued. Rapid atrial pacing is useful for acute conversion of atrial flutter in patients who have pacing wires in place as part of a permanent [[pacemaker]] or [[implantable cardioverter-defibrillator]] or for temporary atrial pacing after cardiac surgery. Acute antithrombotic therapy is recommended in patients with atrial flutter to align with recommended antithrombotic therapy for patients with AF. [[Catheter ablation]] of the CTI (cavotricuspid isthmus) is useful in patients with atrial flutter that is either symptomatic or refractory to pharmacological rate control. [[Beta blockers]], [[diltiazem]], or [[verapamil]] are useful to control the ventricular rate in patients with hemodynamically tolerated atrial flutter.  [[Amiodarone]], [[Dofetilide]], and [[Sotalol] can be useful to maintain sinus rhythm in patients with symptomatic, recurrent atrial flutter, with the drug choice depending on underlying heart disease and comorbidities.<ref name="pmid26409259">{{cite journal| author=Page RL, Joglar JA, Caldwell MA, Calkins H, Conti JB, Deal BJ et al.| title=2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. | journal=J Am Coll Cardiol | year= 2016 | volume= 67 | issue= 13 | pages= e27-e115 | pmid=26409259 | doi=10.1016/j.jacc.2015.08.856 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26409259  }} </ref>  
== Management of Atrial Flutter==
2015 AHA recommendations for the acute and ongoing management of [[atrial flutter]] are described below:<ref name="pmid26409259">{{cite journal| author=Page RL, Joglar JA, Caldwell MA, Calkins H, Conti JB, Deal BJ et al.| title=2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. | journal=J Am Coll Cardiol | year= 2016 | volume= 67 | issue= 13 | pages= e27-e115 | pmid=26409259 | doi=10.1016/j.jacc.2015.08.856 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26409259  }} </ref>
===Acute treatment of Atrial Flutter===

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Oral [[dofetilide]] or intravenous [[ibutilide]] is useful for acute pharmacological cardioversion in patients with atrial flutter <nowiki>"</nowiki>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A ]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Intravenous or oral [[beta blockers]], [[diltiazem]], or [[verapamil]] are useful for acute rate control in patients with atrial flutter who are hemodynamically stable<nowiki>"</nowiki>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Elective [[synchronized cardioversion]] is indicated in stable patients with well-tolerated atrial flutter when a rhythm-control strategy is pursued <nowiki>"</nowiki>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-NR ]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' Synchronized cardioversion is recommended for acute treatment of patients with atrial flutter who are hemodynamically unstable and do not respond to pharmacological therapies <nowiki>"</nowiki>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR ]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' Rapid atrial pacing is useful for acute conversion of atrial flutter in patients who have pacing wires in place as part of a permanent [[pacemaker]] or [[implantable cardioverter-defibrillator]] or for temporary atrial pacing after cardiac surgery<nowiki>"</nowiki>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD ]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' Acute antithrombotic therapy is recommended in patients with atrial flutter to align with recommended antithrombotic therapy for patients with AF <nowiki>"</nowiki>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-NR ]])'' <nowiki>"</nowiki>
|}

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Intravenous [[amiodarone]] can be useful for acute control of the ventricular rate (in the absence of pre-excitation in patients with atrial flutter and systolic [[heart failure]], when beta blockers are contraindicated or ineffective<nowiki>"</nowiki>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-R ]])'' <nowiki>"</nowiki>
|}

===Management of ongoing Atrial Flutter===
{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LightGreen"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Catheter ablation]] of the CTI (cavotricuspid isthmus) is useful in patients with atrial flutter that is either symptomatic or refractory to pharmacological rate control<nowiki>"</nowiki>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-R ]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[Beta blockers]], [[diltiazem]], or [[verapamil]] are useful to control the ventricular rate in patients with hemodynamically tolerated atrial flutter<nowiki>"</nowiki>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C-LD ]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Catheter ablation is useful in patients with recurrent symptomatic non–CTI-dependent flutter after failure of at least 1 antiarrhythmic agent<nowiki>"</nowiki>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C-LD ]])'' <nowiki>"</nowiki>

|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' Ongoing management with antithrombotic therapy is recommended in patients with atrial flutter to align with recommended antithrombotic therapy for patients with AF<nowiki>"</nowiki>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-NR ]])'' <nowiki>"</nowiki>

|}

{|class="wikitable" style="width:80%"
|-
|colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' The following drugs can be useful to maintain sinus rhythm in patients with symptomatic, recurrent atrial flutter, with the drug choice depending on underlying heart disease and comorbidities:
a. [[Amiodarone]] 
b. [[Dofetilide]] 
c. [[Sotalol]]<nowiki>"</nowiki>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-R ]])'' <nowiki>"</nowiki>

|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Catheter ablation is reasonable in patients with CTI-dependent atrial flutter that occurs as the result of flecainide, propafenone, or amiodarone used for treatment of AF<nowiki>"</nowiki>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-NR ]])'' <nowiki>"</nowiki>

|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' Catheter ablation of the CTI is reasonable in patients undergoing catheter ablation of AF who also have a history of documented clinical or induced CTI-dependent atrial flutter <nowiki>"</nowiki>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C-LD ]])'' <nowiki>"</nowiki>

|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' Catheter ablation is reasonable in patients with recurrent symptomatic non–CTI-dependent flutter as primary therapy, before therapeutic trials of antiarrhythmic drugs, after carefully weighing potential risks and benefits of treatment options<nowiki>"</nowiki>''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:C-LD ]])'' <nowiki>"</nowiki>

|}

==References==
{{Reflist|2}}