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Therapeutic Approach

Shown below is an algorithm summarizing the therapeutic approach to atrial flutter.

Atrial flutter

Unstable

Stable

❑ Look for the presence of any of these: ❑ Chronic heart failure ❑ Hypotension ❑ Acute myocardial infarction ❑ If present, attempt direct DC cardioversion and then rate control measures as shown in the table below: ▸ Conversion ▸ DC cardioversion (class I, level of evidence C) ▸ Rate control ▸ Beta blockers (class IIa, level of evidence C) or ▸ Verapamil or diltiazem (class IIa, level of evidence C) or ▸ Digitalis (class IIb, level of evidence C) or ▸ Amiodarone (class IIb, level of evidence C)

❑ Administer anticoagulation therapy based on the risk of stroke, if total duration of flutter > 48 hours ❑ Administer rate control therapy as shown in table below: ▸ Rate control ▸ Beta blockers (class IIa, level of evidence C) or ▸ Verapamil or diltiazem (class IIa, level of evidence C) or ▸ Digitalis (class IIb, level of evidence C) or ▸ Amiodarone (class IIb, level of evidence C)

❑ Attempt conversion as shown in table below: ▸ Conversion ▸ Atrial or transesophageal pacing (class I, level of evidence A) or ▸ DC cardioversion (class I, level of evidence C) or ▸ Ibutilide (class IIa, level of evidence A) or Flecainide (class IIb, level of evidence A) or Propafenone (class IIb, level of evidence A) or Sotalol (class IIb, level of evidence C) or Procainamide (class IIb, level of evidence A) or Amiodarone (class IIb, level of evidence C)

❑ Assess need for therapy to prevent recurrence

❑ Administer antiarrythmic therapy to prevent recurrences as shown below: ▸ First episode and well-tolerated atrial flutter ▸ Cardioversion alone (class I, level of evidence B) or ▸ Catheter ablation (class IIa, level of evidence B) ▸ Recurrent and well-tolerated atrial flutter ▸ Catheter ablation(class I, level of evidence B) or ▸ Dofetilide (class IIa, level of evidence C) or ▸ Amiodarone (class IIb, level of evidence C) or Sotalol or Flecainide or Quinidine or Propafenone or Procainamide or Disopyramide ▸ Poorly tolerated atrial flutter ▸ Catheter ablation (class I, level of evidence B) ▸ Atrial flutter appearing after use of class Ic agents or amiodarone for treatment of AF ▸ Catheter ablation (class I, level of evidence B) or ▸ Stop current drug and use another (class IIa, level of evidence C) ▸ Symptomatic non–CTI-dependent flutter after failed antiarrhythmic drug therapy Catheter ablation (class IIa, level of evidence B) ❑ Consider catheter ablation if antiarrhythmic therapy fails