Atrial flutter

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

haemodynamically unstable

1st line – emergency electrical cardioversion

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1st line –

emergency electrical cardioversion

Urgently identify any patient with features of haemodynamic instability, which include:[5][20]

Shock – see our topic Shock
Syncope
Myocardial ischaemia – see our topics ST-elevation myocardial infarction and Non ST-elevation myocardial infarction
Acute, severe heart failure (characterised by acute pulmonary oedema or raised jugular venous pressure) – see our topic Acute heart failure.

Organise immediate synchronised direct current (DC) cardioversion.[5][20]

Call for anaesthetic support to ensure any conscious patient has sedation or general anaesthesia.[20]
Electrical cardioversion is achieved with synchronised DC cardioversion. Give up to three shocks.[20]
- For the initial shock, use 70 to 120 J of energy.[20]
- Give subsequent shocks using stepwise increases in energy.[20]
If cardioversion has not terminated the atrial flutter after three shocks, further treatment should only be initiated by a specialist.[20]

Consider – pre-cardioversion anticoagulation

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Consider –

pre-cardioversion anticoagulation

Additional treatment recommended for SOME patients in selected patient group

If the patient has new-onset atrial flutter and is receiving no, or subtherapeutic, anticoagulation, start initial parenteral anticoagulation and continue this until you have made a full assessment.[23] This should not delay urgent cardioversion, however.

Choose an appropriate anticoagulant for the patient in line with your hospital protocols. Unfractionated heparin or a low molecular weight heparin (LMWH) such as enoxaparin are options.[23]
Transition patients who are started on unfractionated heparin or an LMWH to a direct oral anticoagulant (e.g., rivaroxaban, apixaban, edoxaban, or dabigatran), or warfarin, when appropriate, and after assessment of stroke and bleeding risk.[23] See Long-term anticoagulation strategy below.

Primary options

heparin: consult specialist for guidance on dose

enoxaparin: consult specialist for guidance on dose

Plus – supportive care

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Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

While assessing the patient, start resuscitation measures. However, do not delay emergency synchronised direct current cardioversion as their condition may be life-threatening.

Monitor controlled oxygen therapy. An upper SpO ₂ limit of 96% is reasonable when administering supplemental oxygen to most patients with acute illness who are not at risk of hypercapnia.
- Evidence suggests that liberal use of supplemental oxygen (target SpO ₂ >96%) in acutely ill adults is associated with higher mortality than more conservative oxygen therapy.[25]
- A lower target SpO ₂ of 88% to 92% is appropriate if the patient is at risk of hypercapnic respiratory failure.[26]
Monitor the ECG and blood pressure.[20]
Obtain intravenous access.[2]
Identify and treat any reversible causes (e.g., electrolyte abnormalities).[20]

Plus – long-term anticoagulation strategy

Back

Plus –

long-term anticoagulation strategy

Treatment recommended for ALL patients in selected patient group

Discuss the patient with a senior colleague and/or a cardiologist when considering long-term anticoagulation in order to weigh up the risks and benefits.

In general, the anticoagulation strategy for atrial flutter should follow the same approach as for atrial fibrillation (AF), particularly if the patient is undergoing cardioversion or has concomitant AF.[5][23][24] See our topic New-onset atrial fibrillation.
In the UK, the National Institute for Health and Care Excellence (NICE) recommends using the CHA ₂DS ₂-VASc score to calculate stroke risk.[23] [ Atrial Fibrillation CHA(2)DS(2)-VASc Score for Stroke Risk Opens in new window ] Although thrombo-embolic risk is lower in atrial flutter than in AF, it is still significant.[5]
If anticoagulation is being considered, use a risk bleeding score to assess the patient’s risk of bleeding.[23]
- NICE recommends using the ORBIT bleeding score to assess bleeding risk, but other bleeding risk scores (such as HAS-BLED) may still be used depending on your local protocol. [ HAS-BLED Bleeding Risk Score Opens in new window ]
- Use a risk bleeding score to:[23][38]Hindricks G, Potpara T, Dagres N, et al. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498.[49]
  - Assess the risk of a major bleed
  - Identify (and subsequently manage) modifiable risk factors for bleeding, such as uncontrolled hypertension, harmful alcohol consumption, labile international normalised ratio (INR; if the patient is on warfarin), and concurrent use of aspirin or a non-steroidal anti-inflammatory drug
  - Flag the ‘high bleeding risk’ patients for early review and follow-up.
If anticoagulation is suitable for the patient, start a direct oral anticoagulant (DOAC) using any one of apixaban, dabigatran, edoxaban, or rivaroxaban.[23]
- If a DOAC is contraindicated, not tolerated, or unsuitable for the patient, use warfarin.[23]
- If the patient is already taking warfarin and their INR is stable, continue warfarin and discuss the option of switching to a DOAC at their next routine appointment, while taking into account the amount of time their INR is in therapeutic range.[23]

Primary options

apixaban: 2.5 to 5 mg orally twice daily

edoxaban: body weight <61 kg: 30 mg orally once daily; body weight ≥61 kg: 60 mg orally once daily

rivaroxaban: 20 mg orally once daily

dabigatran: 18-74 years of age: 150 mg orally twice daily; 75-79 years of age: 110-150 mg orally twice daily; ≥80 years of age: 110 mg orally twice daily

Secondary options

warfarin: 5-10 mg orally once daily initially, adjust dose according to target INR

ACUTE

haemodynamically stable

1st line – rate control

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1st line –

rate control

In practice, start a rate control drug if the patient is tachycardic while you are initially assessing them, before deciding on a rate control strategy or rhythm control strategy (using electrical or pharmacological cardioversion).

In the absence of evidence for choice of initial management strategy in patients with atrial flutter, use a similar approach to atrial fibrillation:
- A rate control strategy if the onset of atrial flutter is >48 hours, or uncertain[23]
- Either a rate control or rhythm control (see Elective electrical cardioversion and Pharmacological cardioversion below) strategy if the onset of atrial flutter is definitely <48 hours.[23]
In addition, always use your clinical judgement when choosing the type of strategy; a rhythm control strategy may be preferred if the patient would be suitable for ablation.[5]
Seek advice from a senior colleague or a specialist if you are unsure.

Use an atrioventricular nodal blocking drug (e.g., a beta-blocker or a non-dihydropyridine calcium-channel blocker) for rate control.[5][23] Base your choice of drug on the patient’s symptoms, heart rate, comorbidities, and preferences.[23] Seek specialist input about choice of drug if you are unsure.

Non-dihydropyridine calcium-channel blockers include verapamil and diltiazem. However, these are contraindicated if the patient has hypotension or heart failure with reduced ejection fraction.[5]
Beta-blockers are contraindicated if the patient has decompensated heart failure.[5]
Digoxin is also an option.[37] In practice, it may convert atrial flutter to atrial fibrillation, which can be easier to manage. See our topic Atrial fibrillation.

Do not use rate control drugs in people with atrial flutter with a pre-excitation syndrome such as Wolff-Parkinson-White syndrome.[38]Hindricks G, Potpara T, Dagres N, et al. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498. In practice, seek advice from a specialist or senior colleague to determine suitable alternatives. See our topic Wolff-Parkinson-White syndrome.

Rate control may be difficult to achieve in practice.[5]

Drug treatment is often ineffective in controlling the rate in patients with atrial flutter. For most patients, therefore, the aim of treatment is to restore sinus rhythm.

Primary options

bisoprolol: 1.25 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day

metoprolol: 2.5 to 5 mg intravenously initially (at a rate of 1-2 mg/minute), may repeat every 5 minutes if required, maximum 10-15 mg/total dose; 50 mg orally (immediate-release) two to three times daily initially, increase gradually according to response, maximum 300 mg/day

esmolol: 500 micrograms/kg/minute intravenous infusion for 1 minute as a loading dose, followed by 50 micrograms/kg/minute infusion for 4 minutes, consult specialist for guidance as further dose titration depends on response; usual maintenance dose 50-200 micrograms/kg/minute

carvedilol: 3.125 mg orally twice daily initially, increase gradually according to response, maximum 50 mg/day (body weight <85 kg) or 100 mg/day (body weight >85 kg)

verapamil: 5-10 mg intravenously over 2 minutes, may repeat after 5-10 minutes if required; 40-120 mg orally (immediate-release) three times daily initially, increase gradually according to response, maximum 480 mg/day

diltiazem: 60 mg orally (immediate-release) three times daily initially, increase gradually according to response, maximum 360 mg/day

Secondary options

digoxin: 0.75 to 1.5 mg/day orally given in divided doses over 24 hours for rapid digitalisation, followed by maintenance dose of 0.125 to 0.25 mg/day

Consider – initial anticoagulation

Plus – treat underlying cause

Plus – long-term anticoagulation strategy

Back

Plus –

long-term anticoagulation strategy

Treatment recommended for ALL patients in selected patient group

Discuss the patient with a senior colleague and/or a cardiologist when considering long-term anticoagulation in order to weigh up the risks and benefits.

In general, the anticoagulation strategy for atrial flutter should follow the same approach as for atrial fibrillation (AF), particularly if the patient is undergoing cardioversion or has concomitant AF.[5][23][24] See our topic New-onset atrial fibrillation.
In the UK, the National Institute for Health and Care Excellence (NICE) recommends using the CHA ₂DS ₂-VASc score to calculate stroke risk.[23] [ Atrial Fibrillation CHA(2)DS(2)-VASc Score for Stroke Risk Opens in new window ] Although thrombo-embolic risk is lower in atrial flutter than in AF, it is still significant.[5]
If anticoagulation is being considered, use a risk bleeding score to assess the patient’s risk of bleeding.[23]
- NICE recommends using the ORBIT bleeding score to assess bleeding risk, but other bleeding risk scores (such as HAS-BLED) may still be used depending on your local protocol. [ HAS-BLED Bleeding Risk Score Opens in new window ]
- Use a risk bleeding score to:[23][38]Hindricks G, Potpara T, Dagres N, et al. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498.[49]
  - Assess the risk of a major bleed
  - Identify (and subsequently manage) modifiable risk factors for bleeding, such as uncontrolled hypertension, harmful alcohol consumption, labile international normalised ratio (INR; if the patient is on warfarin), and concurrent use of aspirin or a non-steroidal anti-inflammatory drug
  - Flag the ‘high bleeding risk’ patients for early review and follow-up.
If anticoagulation is suitable for the patient, start a direct oral anticoagulant (DOAC) using any one of apixaban, dabigatran, edoxaban, or rivaroxaban.[23]
- If a DOAC is contraindicated, not tolerated, or unsuitable for the patient, use warfarin.[23]
- If the patient is already taking warfarin and their INR is stable, continue warfarin and discuss the option of switching to a DOAC at their next routine appointment, while taking into account the time the amount of time their INR is in therapeutic range.[23]

Primary options

apixaban: 2.5 to 5 mg orally twice daily

edoxaban: body weight <61 kg: 30 mg orally once daily; body weight ≥61 kg: 60 mg orally once daily

rivaroxaban: 20 mg orally once daily

dabigatran: 18-74 years of age: 150 mg orally twice daily; 75-79 years of age: 110-150 mg orally twice daily; ≥80 years of age: 110 mg orally twice daily

Secondary options

warfarin: 5-10 mg orally once daily initially, adjust dose according to target INR

Consider – long-term rhythm control strategy

2nd line – elective electrical cardioversion

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2nd line –

elective electrical cardioversion

Organise elective electrical cardioversion if a rhythm control strategy is appropriate in patients for whom the onset of atrial flutter is definitely <48 hours, or if atrial flutter persists despite rate control and treatment of the underlying cause (or in the absence of a reversible cause).[5][23]

Electrical cardioversion is achieved with synchronised direct current cardioversion.
Atrial flutter is extremely responsive to electrical cardioversion.[2][21]January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 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 clinical practice guidelines and the Heart Rhythm Society in collaboration with the Society of Thoracic Surgeons. Circulation. 2019 Jul 9;140(2):e125-51. The success rate for electrical cardioversion, using 5 to 50 J of energy, is 95% to 100%.[39][40][41] Lower amounts of energy are most successful with biphasic rather than monophasic waveforms.

Before cardioversion:

Organise echocardiography[23]
- In general, this should be with transthoracic echocardiography. However, transoesophageal echocardiography is equally effective if the onset of atrial flutter is >48 hours.[23]

Seek senior/specialist advice to consider pre-cardioversion anticoagulation.

High-rate atrial pacing may be considered by a specialist if electrical cardioversion has failed and the patient has an implantable cardioverter defibrillator or permanent pacemaker.[5] However, this is rarely used in practice.

Consider – pre-cardioversion anticoagulation

Back

Consider –

pre-cardioversion anticoagulation

Additional treatment recommended for SOME patients in selected patient group

Choose an appropriate anticoagulant for the patient in line with your hospital protocols. Unfractionated heparin or a low molecular weight heparin (LMWH) such as enoxaparin are options.[23]
Transition patients who are started on unfractionated heparin or an LMWH to a direct oral anticoagulant (e.g., rivaroxaban, apixaban, edoxaban, or dabigatran), or warfarin, when appropriate, and after assessment of stroke and bleeding risk.[23] See Long-term anticoagulation strategy below.

Primary options

heparin: consult specialist for guidance on dose

enoxaparin: consult specialist for guidance on dose

Plus – treat underlying cause

Plus – long-term anticoagulation strategy

Back

Plus –

long-term anticoagulation strategy

Treatment recommended for ALL patients in selected patient group

Discuss the patient with a senior colleague and/or a cardiologist when considering long-term anticoagulation in order to weigh up the risks and benefits.

In general, the anticoagulation strategy for atrial flutter should follow the same approach as for atrial fibrillation (AF), particularly if the patient is undergoing cardioversion or has concomitant AF.[5][23][24] See our topic New-onset atrial fibrillation.
In the UK, the National Institute for Health and Care Excellence (NICE) recommends using the CHA ₂DS ₂-VASc score to calculate stroke risk.[23] [ Atrial Fibrillation CHA(2)DS(2)-VASc Score for Stroke Risk Opens in new window ] Although thrombo-embolic risk is lower in atrial flutter than in AF, it is still significant.[5]
If anticoagulation is being considered, use a risk bleeding score to assess the patient’s risk of bleeding.[23]
- NICE recommends using the ORBIT bleeding score to assess bleeding risk, but other bleeding risk scores (such as HAS-BLED) may still be used depending on your local protocol. [ HAS-BLED Bleeding Risk Score Opens in new window ]
- Use a risk bleeding score to:[23][38]Hindricks G, Potpara T, Dagres N, et al. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498.[49]
  - Assess the risk of a major bleed
  - Identify (and subsequently manage) modifiable risk factors for bleeding, such as uncontrolled hypertension, harmful alcohol consumption, labile international normalised ratio (INR; if the patient is on warfarin), and concurrent use of aspirin or a non-steroidal anti-inflammatory drug
  - Flag the ‘high bleeding risk’ patients for early review and follow-up.
If anticoagulation is suitable for the patient, start a direct oral anticoagulant (DOAC) using any one of apixaban, dabigatran, edoxaban, or rivaroxaban.[23]
- If a DOAC is contraindicated, not tolerated, or unsuitable for the patient, use warfarin.[23]
- If the patient is already taking warfarin and their INR is stable, continue warfarin and discuss the option of switching to a DOAC at their next routine appointment, while taking into account the time the amount of time their INR is in therapeutic range.[23]

Primary options

apixaban: 2.5 to 5 mg orally twice daily

edoxaban: body weight <61 kg: 30 mg orally once daily; body weight ≥61 kg: 60 mg orally once daily

rivaroxaban: 20 mg orally once daily

dabigatran: 18-74 years of age: 150 mg orally twice daily; 75-79 years of age: 110-150 mg orally twice daily; ≥80 years of age: 110 mg orally twice daily

Secondary options

warfarin: 5-10 mg orally once daily initially, adjust dose according to target INR

Plus – continue rate control

3rd line – pharmacological cardioversion

Back

3rd line –

pharmacological cardioversion

Be aware that anti-arrhythmic drugs are generally not effective in re-establishing sinus rhythm; in practice, electrical cardioversion is preferred.[5]

However, consider pharmacological cardioversion if:

Atrial flutter persists despite treatment of any underlying cause, rate control, and electrical cardioversion[5][23]
Electrical cardioversion is unavailable or not acceptable to the patient.[5][23]

Pharmacological cardioversion should only be used:

If the patient has a normal QT interval, and no permanent pacemaker or implantable cardioverter defibrillator[5]
In hospital under specialist supervision.

Pharmacological cardioversion uses an anti-arrhythmic drug, selected according to the patient’s history and condition.[23] Options include:[23]

Flecainide or amiodarone if the patient has no evidence of structural or ischaemic heart disease
Amiodarone if the patient has evidence of structural heart disease
Ibutilide (although this is not available in the UK).[5]

Before cardioversion:

Organise echocardiography[23]
- In general, this should be with transthoracic echocardiography. However, transoesophageal echocardiography is equally effective if the onset of atrial flutter is >48 hours[23]
Seek senior/specialist advice to consider pre-cardioversion anticoagulation. See Pre-cardioversion anticoagulation below
Co-prescribe an atrioventricular (AV) nodal blocking drug if you are giving a class IC anti-arrhythmic drug (e.g., flecainide), to prevent slowing of the atrial rate, which may result in 1:1 AV conduction and a potentially life-threatening ventricular rate.[5]

Monitor the ECG continuously during pharmacological cardioversion.

The major risk associated with pharmacological cardioversion is torsade de pointes. Patients with reduced left ventricular ejection fraction are at the highest risk.

Primary options

flecainide: 200-300 mg orally as a single dose

amiodarone: 5-7 mg/kg intravenously over 1-2 hours, followed by 50 mg/hour intravenous infusion, maximum 1200 mg/day

Consider – pre-cardioversion anticoagulation

Back

Consider –

pre-cardioversion anticoagulation

Additional treatment recommended for SOME patients in selected patient group

Choose an appropriate anticoagulant for the patient in line with your hospital protocols. Unfractionated heparin or a low molecular weight heparin (LMWH) such as enoxaparin are options.[23]
Transition patients who are started on unfractionated heparin or an LMWH to a direct oral anticoagulant (e.g., rivaroxaban, apixaban, edoxaban, or dabigatran), or warfarin, when appropriate, and after assessment of stroke and bleeding risk.[23] See Long-term anticoagulation strategy below.

Primary options

heparin: consult specialist for guidance on dose

enoxaparin: consult specialist for guidance on dose

Plus – treat underlying cause

Plus – long-term anticoagulation strategy

Back

Plus –

long-term anticoagulation strategy

Treatment recommended for ALL patients in selected patient group

Discuss the patient with a senior colleague and/or a cardiologist when considering long-term anticoagulation in order to weigh up the risks and benefits.

In general, the anticoagulation strategy for atrial flutter should follow the same approach as for atrial fibrillation (AF), particularly if the patient is undergoing cardioversion or has concomitant AF.[5][23][24] See our topic New-onset atrial fibrillation.
In the UK, the National Institute for Health and Care Excellence (NICE) recommends using the CHA ₂DS ₂-VASc score to calculate stroke risk.[23] [ Atrial Fibrillation CHA(2)DS(2)-VASc Score for Stroke Risk Opens in new window ] Although thrombo-embolic risk is lower in atrial flutter than in AF, it is still significant.[5]
If anticoagulation is being considered, use a risk bleeding score to assess the patient’s risk of bleeding.[23]
- NICE recommends using the ORBIT bleeding score to assess bleeding risk, but other bleeding risk scores (such as HAS-BLED) may still be used depending on your local protocol. [ HAS-BLED Bleeding Risk Score Opens in new window ]
- Use a risk bleeding score to:[23][38]Hindricks G, Potpara T, Dagres N, et al. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498.[49]
  - Assess the risk of a major bleed
  - Identify (and subsequently manage) modifiable risk factors for bleeding, such as uncontrolled hypertension, harmful alcohol consumption, labile international normalised ratio (INR; if the patient is on warfarin), and concurrent use of aspirin or a non-steroidal anti-inflammatory drug
  - Flag the ‘high bleeding risk’ patients for early review and follow-up.
If anticoagulation is suitable for the patient, start a direct oral anticoagulant (DOAC) using any one of apixaban, dabigatran, edoxaban, or rivaroxaban.[23]
- If a DOAC is contraindicated, not tolerated, or unsuitable for the patient, use warfarin.[23]
- If the patient is already taking warfarin and their INR is stable, continue warfarin and discuss the option of switching to a DOAC at their next routine appointment, while taking into account the time the amount of time their INR is in therapeutic range.[23]

Primary options

apixaban: 2.5 to 5 mg orally twice daily

edoxaban: body weight <61 kg: 30 mg orally once daily; body weight ≥61 kg: 60 mg orally once daily

rivaroxaban: 20 mg orally once daily

dabigatran: 18-74 years of age: 150 mg orally twice daily; 75-79 years of age: 110-150 mg orally twice daily; ≥80 years of age: 110 mg orally twice daily

Secondary options

warfarin: 5-10 mg orally once daily initially, adjust dose according to target INR

ONGOING

recurrent atrial flutter or failure of elective cardioversion

1st line – catheter ablation

Plus – long-term anticoagulation strategy

Back

Plus –

long-term anticoagulation strategy

Treatment recommended for ALL patients in selected patient group

Discuss the patient with a senior colleague and/or a cardiologist when considering long-term anticoagulation in order to weigh up the risks and benefits.

In general, the anticoagulation strategy for atrial flutter should follow the same approach as for atrial fibrillation (AF), particularly if the patient is undergoing cardioversion or has concomitant AF.[5][23][24] See our topic New-onset atrial fibrillation.
In the UK, the National Institute for Health and Care Excellence (NICE) recommends using the CHA ₂DS ₂-VASc score to calculate stroke risk.[23] [ Atrial Fibrillation CHA(2)DS(2)-VASc Score for Stroke Risk Opens in new window ] Although thrombo-embolic risk is lower in atrial flutter than in AF, it is still significant.[5]
If anticoagulation is being considered, use a risk bleeding score to assess the patient’s risk of bleeding.[23]
- NICE recommends using the ORBIT bleeding score to assess bleeding risk, but other bleeding risk scores (such as HAS-BLED) may still be used depending on your local protocol. [ HAS-BLED Bleeding Risk Score Opens in new window ]
- Use a risk bleeding score to:[23][38]Hindricks G, Potpara T, Dagres N, et al. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498.[49]
  - Assess the risk of a major bleed
  - Identify (and subsequently manage) modifiable risk factors for bleeding, such as uncontrolled hypertension, harmful alcohol consumption, labile international normalised ratio (INR; if the patient is on warfarin), and concurrent use of aspirin or a non-steroidal anti-inflammatory drug
  - Flag the ‘high bleeding risk’ patients for early review and follow-up.
If anticoagulation is suitable for the patient, start a direct oral anticoagulant (DOAC) using any one of apixaban, dabigatran, edoxaban, or rivaroxaban.[23]
- If a DOAC is contraindicated, not tolerated, or unsuitable for the patient, use warfarin.[23]
- If the patient is already taking warfarin and their INR is stable, continue warfarin and discuss the option of switching to a DOAC at their next routine appointment, while taking into account the time the amount of time their INR is in therapeutic range.[23]

Primary options

apixaban: 2.5 to 5 mg orally twice daily

edoxaban: body weight <61 kg: 30 mg orally once daily; body weight ≥61 kg: 60 mg orally once daily

rivaroxaban: 20 mg orally once daily

dabigatran: 18-74 years of age: 150 mg orally twice daily; 75-79 years of age: 110-150 mg orally twice daily; ≥80 years of age: 110 mg orally twice daily

Secondary options

warfarin: 5-10 mg orally once daily initially, adjust dose according to target INR

2nd line – long-term rate control

Back

2nd line –

long-term rate control

Give long-term rate control if catheter ablation is not feasible or the patient would prefer drug therapy.[5] However, be aware that drug treatment is often ineffective in controlling the rate in patients with atrial flutter. For most patients, therefore, the aim of treatment is to restore sinus rhythm.

Use an atrioventricular nodal blocking drug (e.g., a beta-blocker, or a non-dihydropyridine calcium-channel blocker).[5]
Base your choice of drug on the patient’s symptoms, heart rate, comorbidities, and preferences.[23]

Do not use rate control drugs in people with atrial flutter with a pre-excitation syndrome such as Wolff-Parkinson-White syndrome.[38]Hindricks G, Potpara T, Dagres N, et al. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498. In practice, seek advice from a specialist or a senior colleague to determine suitable alternatives. See our topic Wolff-Parkinson-White syndrome.

Primary options

bisoprolol: 1.25 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day

metoprolol: 50 mg orally (immediate-release) two to three times daily initially, increase gradually according to response, maximum 300 mg/day

carvedilol: 3.125 mg orally twice daily initially, increase gradually according to response, maximum 50 mg/day (body weight <85 kg) or 100 mg/day (body weight >85 kg)

verapamil: 40-120 mg orally (immediate-release) three times daily initially, increase gradually according to response, maximum 480 mg/day

diltiazem: 60 mg orally (immediate-release) three times daily initially, increase gradually according to response, maximum 360 mg/day

Plus – long-term anticoagulation strategy

Back

Plus –

long-term anticoagulation strategy

Treatment recommended for ALL patients in selected patient group

Discuss the patient with a senior colleague and/or a cardiologist when considering long-term anticoagulation in order to weigh up the risks and benefits.

In general, the anticoagulation strategy for atrial flutter should follow the same approach as for atrial fibrillation (AF), particularly if the patient is undergoing cardioversion or has concomitant AF.[5][23][24] See our topic New-onset atrial fibrillation.
In the UK, the National Institute for Health and Care Excellence (NICE) recommends using the CHA ₂DS ₂-VASc score to calculate stroke risk.[23] [ Atrial Fibrillation CHA(2)DS(2)-VASc Score for Stroke Risk Opens in new window ] Although thrombo-embolic risk is lower in atrial flutter than in AF, it is still significant.[5]
If anticoagulation is being considered, use a risk bleeding score to assess the patient’s risk of bleeding.[23]
- NICE recommends using the ORBIT bleeding score to assess bleeding risk, but other bleeding risk scores (such as HAS-BLED) may still be used depending on your local protocol. [ HAS-BLED Bleeding Risk Score Opens in new window ]
- Use a risk bleeding score to:[23][38]Hindricks G, Potpara T, Dagres N, et al. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021 Feb 1;42(5):373-498.[49]
  - Assess the risk of a major bleed
  - Identify (and subsequently manage) modifiable risk factors for bleeding, such as uncontrolled hypertension, harmful alcohol consumption, labile international normalised ratio (INR; if the patient is on warfarin), and concurrent use of aspirin or a non-steroidal anti-inflammatory drug
  - Flag the ‘high bleeding risk’ patients for early review and follow-up.
If anticoagulation is suitable for the patient, start a direct oral anticoagulant (DOAC) using any one of apixaban, dabigatran, edoxaban, or rivaroxaban.[23]
- If a DOAC is contraindicated, not tolerated, or unsuitable for the patient, use warfarin.[23]
- If the patient is already taking warfarin and their INR is stable, continue warfarin and discuss the option of switching to a DOAC at their next routine appointment, while taking into account the time the amount of time their INR is in therapeutic range.[23]

Primary options

apixaban: 2.5 to 5 mg orally twice daily

edoxaban: body weight <61 kg: 30 mg orally once daily; body weight ≥61 kg: 60 mg orally once daily

rivaroxaban: 20 mg orally once daily

dabigatran: 18-74 years of age: 150 mg orally twice daily; 75-79 years of age: 110-150 mg orally twice daily; ≥80 years of age: 110 mg orally twice daily

Secondary options

warfarin: 5-10 mg orally once daily initially, adjust dose according to target INR

Consider – long-term anti-arrhythmic therapy

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Consider –

long-term anti-arrhythmic therapy

Additional treatment recommended for SOME patients in selected patient group

Consider anti-arrhythmic therapy to maintain sinus rhythm if atrial flutter persists despite rate control.[5]

Use amiodarone if the patient has heart failure or structural heart disease.[5]
Do not give a class 1c anti-arrhythmic drug (e.g., flecainide or propafenone):
- To a patient with known ischaemic or structural heart disease[23]
- Without co-prescribing an atrioventricular (AV) nodal blocking drug because of the risk of slowing of the atrial rate, which may result in 1:1 AV conduction and a potentially life-threatening ventricular rate.[5]

Primary options

flecainide: 50 mg orally twice daily initially, increase gradually according to response, maximum 300 mg/day

propafenone: 150 mg orally three times daily initially, increase gradually according to response, maximum 900 mg/day

amiodarone: 200 mg orally three times daily initially for 1 week, then reduce to 200 mg twice daily for 1 week, followed by 200 mg once daily (or the minimum dose required to control arrhythmia)

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Atrial flutter

Treatment algorithm

haemodynamically unstable

emergency electrical cardioversion

pre-cardioversion anticoagulation

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

supportive care

long-term anticoagulation strategy

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

haemodynamically stable

rate control

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

initial anticoagulation

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

treat underlying cause

long-term anticoagulation strategy

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

long-term rhythm control strategy

elective electrical cardioversion

pre-cardioversion anticoagulation

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

treat underlying cause

long-term anticoagulation strategy

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

continue rate control

pharmacological cardioversion

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

pre-cardioversion anticoagulation

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

treat underlying cause

long-term anticoagulation strategy

Primary options