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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, treat 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 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) THEN ❑ 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