Atrial flutter medical therapy: Difference between revisions
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{{Atrial flutter}} | {{Atrial flutter}} | ||
{{CMG}}; {{AE}} {{RT}} | {{CMG}}; {{AE}} {{RT}} | ||
==Overview== | ==Overview== | ||
The management of atrial flutter is similar to that of [[atrial fibrillation]] with primary goals being control of ventricular rate, restoration of sinus rhythm, prevention of recurrent episodes and thromboembolic episodes. In the setting of unstable hemodynamics immediate electrical [[cardioversion]] is recommended. because of the high success rate and low complication rate [[radiofrequency ablation]] is considered superior to medical therapy in atrial flutter. | The management of atrial flutter is similar to that of [[atrial fibrillation]] with primary goals being control of ventricular rate, restoration of [[sinus rhythm]], and prevention of recurrent episodes and [[Thromboembolic disease|thromboembolic]] episodes. In the setting of unstable hemodynamics immediate electrical [[cardioversion]] is recommended. because of the high success rate and low complication rate [[radiofrequency ablation]] is considered superior to medical therapy in atrial flutter. | ||
==Medical Therapy== | ==Medical Therapy== | ||
=== | Treatment goals in the management of atrial flutter include:<ref name="pmid9362409">{{cite journal |vauthors=Lanzarotti CJ, Olshansky B |title=Thromboembolism in chronic atrial flutter: is the risk underestimated? |journal=J. Am. Coll. Cardiol. |volume=30 |issue=6 |pages=1506–11 |date=November 1997 |pmid=9362409 |doi=10.1016/s0735-1097(97)00326-4 |url=}}</ref><ref name="pmid24685669">{{cite journal| author=January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC | display-authors=etal| title=2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. | journal=J Am Coll Cardiol | year= 2014 | volume= 64 | issue= 21 | pages= e1-76 | pmid=24685669 | doi=10.1016/j.jacc.2014.03.022 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24685669 }}</ref> | ||
* | * Control of ventricular rate | ||
* | * Reversion to [[normal sinus rhythm]] (NSR) | ||
* | * Prevention of recurrent episodes and prevention of [[systemic embolization]] | ||
Treatment modalities for atrial flutter include: | |||
====Electric Cardioversion==== | ====Electric Cardioversion==== | ||
Synchronous direct current (DC) cardioversion is used as the initial treatment in the management of atrial flutter in | *Synchronous direct current (DC) [[cardioversion]] is used as the initial treatment strategy in the management of [[hemodynamically unstable]] atrial flutter patients in the emergency department. External electrical [[cardioversion]] is effective in more than 90% of the cases and the initial shock strength used is 50 joules biphasic direct current.<ref name="pmid9038696">{{cite journal |vauthors=Crijns HJ, Van Gelder IC, Tieleman RG, Brügemann J, De Kam PJ, Gosselink AT, Bink-Boelkens MT, Lie KI |title=Long-term outcome of electrical cardioversion in patients with chronic atrial flutter |journal=Heart |volume=77 |issue=1 |pages=56–61 |date=January 1997 |pmid=9038696 |pmc=484636 |doi=10.1136/hrt.77.1.56 |url=}}</ref> | ||
*Sometimes the first shock may convert an atrial flutter to atrial fibrillation, in such cases a second shock preferable of a higher strength is usually given to restore [[sinus rhythm]]. | |||
*Electric [[cardioversion]] increases the risk of [[stroke]] and hence pre-treatment with a blood thinner is advised if time permits. | |||
====AV Nodal Agents==== | |||
*Ventricular rate control is the prime goal in the management of atrial flutter.<ref name="pmid12163422">{{cite journal| author=Wellens HJ| title=Contemporary management of atrial flutter. | journal=Circulation | year= 2002 | volume= 106 | issue= 6 | pages= 649-52 | pmid=12163422 | doi=10.1161/01.cir.0000027683.00417.9a | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12163422 }}</ref> | |||
*Drugs such as [[Calcium channel blocker|calcium channel blockers]] ([[verapamil]] or [[diltiazem]]) or [[beta-blocker]]s can be used for this. These drugs act as AV node blocking agents and control ventricular rate, thereby preventing [[tachycardia induced cardiomyopathy]]. | |||
*Beta-blockers also have a direct [[Antiarrhythmic agent|antiarrhythmic]] effect on the atria. Administration of [[adenosine]] reveals flutter waves by blocking the [[AV node]]. | |||
*History of [[Wolff-Parkinson-White syndrome]] or [[pre-excitation syndrome]] has to be ruled out before administrating, as these agents while acting on AV node can accelerate conduction in the accessory pathways and can precipitate [[ventricular fibrillation]]. | |||
*[[Digoxin]] can also be used as an AV blocking agent in combination with [[calcium channel blockers]] and [[beta-blockers]] in the event of failure of electric [[cardioversion]], atrial pacing and pharmacologic therapy. | |||
====Antiarrhythmic Agents==== | |||
*Class III agents like [[ibutilide]], [[dofetilide]], [[sotalol]] or [[amiodarone]] are typically used for pharmacologic [[cardioversion]] in the treatment of atrial flutter.<ref name="pmid10078083">{{cite journal |vauthors=Vos MA, Golitsyn SR, Stangl K, Ruda MY, Van Wijk LV, Harry JD, Perry KT, Touboul P, Steinbeck G, Wellens HJ |title=Superiority of ibutilide (a new class III agent) over DL-sotalol in converting atrial flutter and atrial fibrillation. The Ibutilide/Sotalol Comparator Study Group |journal=Heart |volume=79 |issue=6 |pages=568–75 |date=June 1998 |pmid=10078083 |pmc=1728725 |doi=10.1136/hrt.79.6.568 |url=}}</ref> | |||
*Intravenous ibutilide is very effective in controlling acute atrial flutter episodes and is found to be effective in at least 63% of patients. | |||
*Patients who are administered i.v ibutilide should be monitored using an EKG for at least 4 hrs after the infusion as [[ibutilide]] is known to cause [[QT prolongation]] and [[torsades de pointes]]. | |||
*Class IC agents like [[propafenone]] or [[flecainide]] have also shown to be effective in the conversion of acute onset atrial flutter to [[normal sinus rhythm]]. | |||
====Rapid Atrial Pacing==== | |||
*As external electrical [[cardioversion]] requires anesthesia some doctors prefer atrial overdrive pacing to terminate episodes of atrial flutter. | |||
*In overdrive pacing the atria are continuously paced at a rate higher than that of the patient's sinus node, which causes an alteration in the atrial rate, propagation and also suppresses the [[automaticity]] caused by electrical remodeling in the diseased fibers. Unsuccessful pacing can be due to:<ref name="pmid64788432">{{cite journal |vauthors=Rozsíval V, Kvasnicka J |title=Atrial flutter treatment by rapid atrial pacing |journal=Cor Vasa |volume=26 |issue=3 |pages=167–72 |date=1984 |pmid=6478843 |doi= |url=}}</ref> | |||
====Contraindicated medications==== | |||
* Insufficient rate and duration of pacing | |||
* Bad [[electrode]] contact in the [[Atrium (heart)|atrium]] | |||
* Insufficient outlet current | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
{{WH}} | |||
{{WS}} | |||
[[Category:Electrophysiology]] | [[Category:Electrophysiology]] | ||
[[Category:Disease]] | [[Category:Disease]] | ||
[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
[[Category:Best pages]] | |||
[[Category:Up-To-Date cardiology]] | |||
[[Category:Up-To-Date]] | |||
Latest revision as of 16:16, 16 April 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2]
Overview
The management of atrial flutter is similar to that of atrial fibrillation with primary goals being control of ventricular rate, restoration of sinus rhythm, and prevention of recurrent episodes and thromboembolic episodes. In the setting of unstable hemodynamics immediate electrical cardioversion is recommended. because of the high success rate and low complication rate radiofrequency ablation is considered superior to medical therapy in atrial flutter.
Medical Therapy
Treatment goals in the management of atrial flutter include:[1][2]
- Control of ventricular rate
- Reversion to normal sinus rhythm (NSR)
- Prevention of recurrent episodes and prevention of systemic embolization
Treatment modalities for atrial flutter include:
Electric Cardioversion
- Synchronous direct current (DC) cardioversion is used as the initial treatment strategy in the management of hemodynamically unstable atrial flutter patients in the emergency department. External electrical cardioversion is effective in more than 90% of the cases and the initial shock strength used is 50 joules biphasic direct current.[3]
- Sometimes the first shock may convert an atrial flutter to atrial fibrillation, in such cases a second shock preferable of a higher strength is usually given to restore sinus rhythm.
- Electric cardioversion increases the risk of stroke and hence pre-treatment with a blood thinner is advised if time permits.
AV Nodal Agents
- Ventricular rate control is the prime goal in the management of atrial flutter.[4]
- Drugs such as calcium channel blockers (verapamil or diltiazem) or beta-blockers can be used for this. These drugs act as AV node blocking agents and control ventricular rate, thereby preventing tachycardia induced cardiomyopathy.
- Beta-blockers also have a direct antiarrhythmic effect on the atria. Administration of adenosine reveals flutter waves by blocking the AV node.
- History of Wolff-Parkinson-White syndrome or pre-excitation syndrome has to be ruled out before administrating, as these agents while acting on AV node can accelerate conduction in the accessory pathways and can precipitate ventricular fibrillation.
- Digoxin can also be used as an AV blocking agent in combination with calcium channel blockers and beta-blockers in the event of failure of electric cardioversion, atrial pacing and pharmacologic therapy.
Antiarrhythmic Agents
- Class III agents like ibutilide, dofetilide, sotalol or amiodarone are typically used for pharmacologic cardioversion in the treatment of atrial flutter.[5]
- Intravenous ibutilide is very effective in controlling acute atrial flutter episodes and is found to be effective in at least 63% of patients.
- Patients who are administered i.v ibutilide should be monitored using an EKG for at least 4 hrs after the infusion as ibutilide is known to cause QT prolongation and torsades de pointes.
- Class IC agents like propafenone or flecainide have also shown to be effective in the conversion of acute onset atrial flutter to normal sinus rhythm.
Rapid Atrial Pacing
- As external electrical cardioversion requires anesthesia some doctors prefer atrial overdrive pacing to terminate episodes of atrial flutter.
- In overdrive pacing the atria are continuously paced at a rate higher than that of the patient's sinus node, which causes an alteration in the atrial rate, propagation and also suppresses the automaticity caused by electrical remodeling in the diseased fibers. Unsuccessful pacing can be due to:[6]
Contraindicated medications
- Insufficient rate and duration of pacing
- Bad electrode contact in the atrium
- Insufficient outlet current
References
- ↑ Lanzarotti CJ, Olshansky B (November 1997). "Thromboembolism in chronic atrial flutter: is the risk underestimated?". J. Am. Coll. Cardiol. 30 (6): 1506–11. doi:10.1016/s0735-1097(97)00326-4. PMID 9362409.
- ↑ January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC; et al. (2014). "2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society". J Am Coll Cardiol. 64 (21): e1–76. doi:10.1016/j.jacc.2014.03.022. PMID 24685669.
- ↑ Crijns HJ, Van Gelder IC, Tieleman RG, Brügemann J, De Kam PJ, Gosselink AT, Bink-Boelkens MT, Lie KI (January 1997). "Long-term outcome of electrical cardioversion in patients with chronic atrial flutter". Heart. 77 (1): 56–61. doi:10.1136/hrt.77.1.56. PMC 484636. PMID 9038696.
- ↑ Wellens HJ (2002). "Contemporary management of atrial flutter". Circulation. 106 (6): 649–52. doi:10.1161/01.cir.0000027683.00417.9a. PMID 12163422.
- ↑ Vos MA, Golitsyn SR, Stangl K, Ruda MY, Van Wijk LV, Harry JD, Perry KT, Touboul P, Steinbeck G, Wellens HJ (June 1998). "Superiority of ibutilide (a new class III agent) over DL-sotalol in converting atrial flutter and atrial fibrillation. The Ibutilide/Sotalol Comparator Study Group". Heart. 79 (6): 568–75. doi:10.1136/hrt.79.6.568. PMC 1728725. PMID 10078083.
- ↑ Rozsíval V, Kvasnicka J (1984). "Atrial flutter treatment by rapid atrial pacing". Cor Vasa. 26 (3): 167–72. PMID 6478843.