Treatment algorithm

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

hemodynamically unstable

1st line – synchronized cardioversion

Back
INITIAL
|
hemodynamically unstable
1st line – 

synchronized cardioversion

If atrial flutter is associated with acute hemodynamic collapse involving symptomatic hypotension, congestive heart failure evidenced by pulmonary edema and/or elevated serum brain natriuretic peptide, or myocardial ischemia (acute ischemic ECG changes, angina), emergent direct current (DC)-synchronized cardioversion is indicated.[6][23]

This rhythm is generally successfully cardioverted with monophasic shocks using <50 J of energy, although the higher-energy initial shocks are indicated for emergency therapy.[4]​ ​Initiation of anticoagulation should not delay DC cardioversion in patients with hemodynamic instability.​[20]

ACUTE

hemodynamically stable

1st line – beta-blocker or calcium-channel blocker or amiodarone

Back
ACUTE
|
hemodynamically stable
1st line – 

beta-blocker or calcium-channel blocker or amiodarone

Beta-blockers are indicated for rate control in patients with atrial flutter complicating acute coronary syndromes to reduce myocardial oxygen demands.[20]​​ Beta-blockers should be used with caution in patients with COPD or asthma, because they might provoke bronchospasm; calcium-channel blockers are preferred if chronic lung disease is also present. Calcium-channel blockers are generally contraindicated or used with extreme caution in patients with heart failure.[8]​ Intravenous amiodarone is 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.[8]

Primary options

metoprolol tartrate: 2.5 to 5 mg intravenous bolus over 2 minutes initially, may repeat every 5 minutes to a total of 3 doses, followed by 25-100 mg orally (immediate-release) twice daily

OR

esmolol: 500 micrograms/kg intravenously over 1 minute as a loading dose, followed by 50 micrograms/kg/min infusion for 4 minutes, if no response after 5 minutes, repeat loading dose and increase infusion; consult specialist for further guidance on dose

OR

diltiazem: 0.25 mg/kg/dose intravenous bolus over 2 minutes initially, may give second dose of 0.35 mg/kg/dose bolus over 2 minutes if necessary, followed by 5-15 mg/hour infusion

OR

verapamil: 2.5 to 10 mg intravenous bolus over 2 minutes initially, may give second dose of 5-10 mg bolus after 30 minutes if necessary, followed by 0.005 mg/kg/min infusion

Secondary options

amiodarone: 150 mg intravenously over 10 minutes initially, followed by 0.5 to 1 mg/minute infusion

Plus – anticoagulation

Back
ACUTE
|
hemodynamically stable
Plus – 

anticoagulation

Treatment recommended for ALL patients in selected patient group

The guidelines for thromboembolic prophylaxis in atrial flutter are the same as those for atrial fibrillation.​​​​​[8][20]​​​​​​​​[22]​​[45]​​​​​[46]

Selection of stroke risk reduction therapy should be guided by the patient’s risk of stroke, risks of bleeding with therapy, and their individual preferences.[20]​ The ​American Heart Association (AHA) and European Society of Cardiology (ESC) guidelines emphasize a risk factor-based approach using a validated clinical risk score such as the CHA2DS2-VASc score system.​[8][20]​​​ [ Atrial Fibrillation CHA(2)DS(2)-VASc Score for Stroke Risk Opens in new window ] ​​​ The CHA2DS2-VASc score is considered the most validated score; however, newer online calculators for risk scores, such as ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) and GARFIELD (Global Anticoagulant Registry in the Field-Atrial Fibrillation), in comparison to CHA2DS2-VASc, may modestly improve discrimination between high versus low risk and may offer potential advantages in specific populations.[8][20] [ Atrial Fibrillation CHA(2)DS(2)-VASc Score for Stroke Risk Opens in new window ] ​​ The HAS-BLED score can be used to assess bleeding risk.[20]​​ [ HAS-BLED Bleeding Risk Score Opens in new window ] ​​​​​​​

The key options for anticoagulation are a vitamin K antagonist such as warfarin, or a direct oral anticoagulant (DOAC) such as dabigatran (a direct thrombin inhibitor), rivaroxaban, apixaban, or edoxaban (direct factor Xa inhibitors). Both vitamin K antagonists and DOACs are approved as efficacious agents for stroke prevention in this patient population.[20]​ In patients who are candidates for anticoagulation and do not have either moderate-severe rheumatic mitral stenosis or mechanical heart valves, DOACs are recommended over warfarin to reduce the risk of mortality, stroke, systemic embolism and intracranial hemorrhage.[20]​ While it is reasonable to use DOACs as first-line agents or as a subsequent replacement for warfarin in patients with atrial flutter, warfarin remains the first-line therapy in patients with AF and moderate-severe rheumatic mitral stenosis or mechanical heart valves.[20]​ DOACs are recommended over warfarin in eligible patients (i.e., patients who do not have moderate-to-severe mitral stenosis or a mechanical heart valve).[20]​ ​ ​​​​Bridging with a parenteral anticoagulant is not necessary when initiating DOACs for this indication. DOACs do not require monitoring of anticoagulant activity; however, they must be used with caution in patients with renal impairment and a dose adjustment may be necessary.​ In the event of major bleeding, the effects of dabigatran can be reversed with idarucizumab; for reversal of apixaban, rivaroxaban, or edoxaban, andexanet alfa (recombinant coagulation factor Xa) can be used.[20]​ ​ Edoxaban should not be used in patients with a creatinine clearance >95 mL/minute because of an increased risk of ischemic stroke.[20]​ ​Initial anticoagulation with subcutaneous low molecular weight heparin (LMWH) or intravenous unfractionated heparin may be necessary for patients presenting acutely with atrial flutter, pending full evaluation and selection of ongoing antithrombotic therapy (recommendations vary according to duration of symptoms and timing of cardioversion).​​​

Warfarin is an alternative to DOAC therapy indicated for selected patients (e.g., patients with mechanical heart valves, clinically significant rheumatic mitral stenosis. Intravenous unfractionated heparin or subcutaneous LMWH should be continued until an INR of 2-3 is achieved with warfarin therapy (bridging therapy).​[20]

If there are no risk factors for stroke, aspirin either alone or in combination with clopidogrel is not recommended to reduce the risk of stroke or to prevent thromboembolic events.[20]

Anticoagulation should be established before cardioversion and is continued for at least 4 weeks after cardioversion, and may be required for longer in some patients.[20]

For more detailed anticoagulation recommendations, see New-onset atrial fibrillation.

Primary options

dabigatran etexilate: 150 mg orally twice daily

OR

apixaban: 2.5 to 5 mg orally twice daily

OR

edoxaban: 60 mg orally once daily

OR

rivaroxaban: 20 mg orally once daily

Secondary options

heparin: see local protocol for dosing guidelines, maintain activated partial thromboplastin time (aPTT) at 45-60 seconds

or

enoxaparin: 1 mg/kg subcutaneously every 12 hours

-- AND --

warfarin: 2-5 mg orally once daily initially, adjust dose according to target INR

More

Plus – treat coexisting acute disease process

Back
ACUTE
|
hemodynamically stable
Plus – 

treat coexisting acute disease process

Treatment recommended for ALL patients in selected patient group

In approximately 60% of patients, atrial flutter accompanies an acute illness and resolves with that disease process.[5]

2nd line – synchronized cardioversion

Back
ACUTE
|
hemodynamically stable
2nd line – 

synchronized cardioversion

Recommended for acute treatment of patients who do not respond to pharmacologic therapy.

The decision to perform a transesophageal echocardiogram prior to cardioversion to assess for left atrial or appendage thrombus should follow the recommendations for atrial fibrillation.​[20]

The success rate for external direct current cardioversion is 95% to 100% and can be generally achieved using 5-50 J of energy. Lower amounts are most successful with biphasic versus monophasic waveforms. However, higher energies may be needed.[23][34][35][36]

Rate-control agents are continued before cardioversion and discontinued when sinus rhythm is restored. However, they can be continued afterward to prevent rapid ventricular rate in case of recurrence. Dosage may need to be decreased after cardioversion if there is bradycardia or hypotension.

Plus – anticoagulation

Back
ACUTE
|
hemodynamically stable
Plus – 

anticoagulation

Treatment recommended for ALL patients in selected patient group

The guidelines for thromboembolic prophylaxis in atrial flutter are the same as those for atrial fibrillation.​​​​​[8]​​​​​​​[20][22]​​[45]​​​​​[46]

Selection of stroke risk reduction therapy should be guided by the patient’s risk of stroke, risks of bleeding with therapy, and their individual preferences.[20]​ The ​AHA and ESC guidelines emphasize a risk factor-based approach using a validated clinical risk score such as the CHA2DS2-VASc score system.[8][20] [ Atrial Fibrillation CHA(2)DS(2)-VASc Score for Stroke Risk Opens in new window ] ​​​​​ The CHA2DS2-VASc score is considered the most validated score; however, newer online calculators for risk scores, such as ATRIA and GARFIELD, in comparison to CHA2DS2-VASc, may modestly improve discrimination between high versus low risk and may offer potential advantages in specific populations.​[8][20]​​​​​ [ Atrial Fibrillation CHA(2)DS(2)-VASc Score for Stroke Risk Opens in new window ] ​​​​​​ The HAS-BLED score can be used to assess bleeding risk.[20]​​ [ HAS-BLED Bleeding Risk Score Opens in new window ] ​​​​​​​​​

The key options for anticoagulation are a vitamin K antagonist such as warfarin, or a DOAC such as dabigatran (a direct thrombin inhibitor), rivaroxaban, apixaban, or edoxaban (direct factor Xa inhibitors). Both vitamin K antagonists and DOACs are approved as efficacious agents for stroke prevention in this patient population.[20]​ In patients who are candidates for anticoagulation and do not have either moderate-severe rheumatic mitral stenosis or mechanical heart valves, DOACs are recommended over warfarin to reduce the risk of mortality, stroke, systemic embolism and intracranial hemorrhage.[20]​ While it is reasonable to use DOACs as first-line agents or as a subsequent replacement for warfarin in patients with atrial flutter, warfarin remains the first-line therapy in patients with AF and moderate-severe rheumatic mitral stenosis or mechanical heart valves.[20]​ DOACs are recommended over warfarin in eligible patients (i.e., patients who do not have moderate-to-severe mitral stenosis or a mechanical heart valve).[20]​ Bridging with a parenteral anticoagulant is not necessary when initiating DOACs for this indication. DOACs do not require monitoring of anticoagulant activity; however, they must be used with caution in patients with renal impairment and a dose adjustment may be necessary.​ In the event of major bleeding, the effects of dabigatran can be reversed with idarucizumab; for reversal of apixaban, rivaroxaban or edoxaban, andexanet alfa (recombinant coagulation factor Xa) can be used.[20] Edoxaban should not be used in patients with a creatinine clearance >95 mL/minute because of an increased risk of ischemic stroke.[20]​ ​Initial anticoagulation with subcutaneous LMWH or intravenous unfractionated heparin may be necessary for patients presenting acutely with atrial flutter, pending full evaluation and selection of ongoing antithrombotic therapy (recommendations vary according to duration of symptoms and timing of cardioversion).​​​​

Warfarin is an alternative to DOAC therapy indicated for selected patients (e.g., patients with mechanical heart valves, clinically significant rheumatic mitral stenosis. Intravenous unfractionated heparin or subcutaneous LMWH should be continued until an INR of 2-3 is achieved with warfarin therapy (bridging therapy).​[20]

If there are no risk factors for stroke, aspirin either alone or in combination with clopidogrel is not recommended to reduce the risk of stroke or to prevent thromboembolic events.[20]

Anticoagulation should be established before cardioversion and is continued for at least 4 weeks after cardioversion, and may be required for longer in some patients.[20]

For more detailed anticoagulation recommendations, see New-onset atrial fibrillation.

Primary options

dabigatran etexilate: 150 mg orally twice daily

OR

apixaban: 2.5 to 5 mg orally twice daily

OR

edoxaban: 60 mg orally once daily

OR

rivaroxaban: 20 mg orally once daily

Secondary options

heparin: see local protocol for dosing guidelines, maintain activated partial thromboplastin time (aPTT) at 45-60 seconds

or

enoxaparin: 1 mg/kg subcutaneously every 12 hours

-- AND --

warfarin: 2-5 mg orally once daily initially, adjust dose according to target INR

More

Plus – treat coexisting acute disease process

Back
ACUTE
|
hemodynamically stable
Plus – 

treat coexisting acute disease process

Treatment recommended for ALL patients in selected patient group

In approximately 60% of patients, atrial flutter accompanies an acute illness and resolves with that disease process.[5]

3rd line – pharmacologic conversion

Back
ACUTE
|
hemodynamically stable
3rd line – 

pharmacologic conversion

May be considered if electrical cardioversion is unavailable, or if the patient does not consent to electrical cardioversion. It is also an option when sedation is not tolerated or available. To be a candidate, a patient must have a normal QT interval and no structural heart disease.

Intravenous ibutilide is the preferred agent for pharmacologic cardioversion; however, oral dofetilide may also be used.[4] Dofetilide is contraindicated in patients with long QT syndrome, QT prolongation, renal failure, and torsade de pointes. It requires specialist inpatient monitoring and should only be initiated by a physician experienced with its use.

Less effective than synchronized cardioversion, with potential for being proarrhythmic. Mean time to conversion is reported to be 30 minutes in those who respond (38% to 76%). Ventricular proarrhythmia, specifically sustained polymorphic ventricular tachycardia, occurs at a rate of 1.2% to 1.7%.[37][38][39][40]

The major risk associated with pharmacologic cardioversion is torsade de pointes. Patients with reduced left ventricular ejection fraction are at the highest risk. Pretreatment with magnesium may reduce the risk of torsade de pointes.

Continuous ECG monitoring is required during administration of these agents and for at least 4 hours after completion of therapy (ibutilide), or at least 3 days (or 12 hours after conversion to normal sinus rhythm, whichever is greater) after completion of therapy (dofetilide).

Primary options

ibutilide: 0.01 mg/kg/dose intravenously (maximum 1 mg/dose) over 10 minutes initially, may repeat 10 minutes after initial dose if no response

Secondary options

dofetilide: dose depends on QTc and renal function; consult specialist for guidance on dose

Plus – anticoagulation

Back
ACUTE
|
hemodynamically stable
Plus – 

anticoagulation

Treatment recommended for ALL patients in selected patient group

The guidelines for thromboembolic prophylaxis in atrial flutter are the same as those for atrial fibrillation.​​​​​[8][20]​​​​​​​​[22]​​[45]​​​​​[46]

Selection of stroke risk reduction therapy should be guided by the patient’s risk of stroke, risks of bleeding with therapy, and their individual preferences.[20]​ The ​AHA and ESC guidelines emphasize a risk factor-based approach using a validated clinical risk score such as the CHA2DS2-VASc score system.[8][20] [ Atrial Fibrillation CHA(2)DS(2)-VASc Score for Stroke Risk Opens in new window ] ​​​​ The CHA2DS2-VASc score is considered the most validated score; however, newer online calculators for risk scores, such as ATRIA and GARFIELD, in comparison to CHA2DS2-VASc, may modestly improve discrimination between high versus low risk and may offer potential advantages in specific populations.​[8]​​[20] [ Atrial Fibrillation CHA(2)DS(2)-VASc Score for Stroke Risk Opens in new window ] ​​​​​ The HAS-BLED score can be used to assess bleeding risk.[20]​​ [ HAS-BLED Bleeding Risk Score Opens in new window ] ​​​​​​​​

The key options for anticoagulation are a vitamin K antagonist such as warfarin, or a DOAC such as dabigatran (a direct thrombin inhibitor), rivaroxaban, apixaban, or edoxaban (direct factor Xa inhibitors). Both vitamin K antagonists and DOACs are approved as efficacious agents for stroke prevention in this patient population.[20]​ In patients who are candidates for anticoagulation and do not have either moderate-severe rheumatic mitral stenosis or mechanical heart valves, DOACs are recommended over warfarin to reduce the risk of mortality, stroke, systemic embolism and intracranial hemorrhage.[20]​ While it is reasonable to use DOACs as first-line agents or as a subsequent replacement for warfarin in patients with atrial flutter, warfarin remains the first-line therapy in patients with AF and moderate-severe rheumatic mitral stenosis or mechanical heart valves.[20]​ DOACs are recommended over warfarin in eligible patients (i.e., patients who do not have moderate-to-severe mitral stenosis or a mechanical heart valve).[20]​ Bridging with a parenteral anticoagulant is not necessary when initiating DOACs for this indication. DOACs do not require monitoring of anticoagulant activity; however, they must be used with caution in patients with renal impairment and a dose adjustment may be necessary.​ In the event of major bleeding, the effects of dabigatran can be reversed with idarucizumab; for reversal of apixaban, rivaroxaban or edoxaban, andexanet alfa (recombinant coagulation factor Xa) can be used.[20]​ Edoxaban should not be used in patients with a creatinine clearance >95 mL/minute because of an increased risk of ischemic stroke.[20]​ ​​Initial anticoagulation with subcutaneous LMWH or intravenous unfractionated heparin may be necessary for patients presenting acutely with atrial flutter, pending full evaluation and selection of ongoing antithrombotic therapy (recommendations vary according to duration of symptoms and timing of cardioversion).​

Warfarin is an alternative to DOAC therapy indicated for selected patients (e.g., patients with mechanical heart valves, clinically significant rheumatic mitral stenosis. Intravenous unfractionated heparin or subcutaneous LMWH should be continued until an INR of 2-3 is achieved with warfarin therapy (bridging therapy).​[20]

If there are no risk factors for stroke, aspirin either alone or in combination with clopidogrel is not recommended to reduce the risk of stroke or to prevent thromboembolic events.[20]

Anticoagulation should be established before cardioversion and is continued for at least 4 weeks after cardioversion, and may be required for longer in some patients.[20]

For more detailed anticoagulation recommendations, see New-onset atrial fibrillation.

Primary options

dabigatran etexilate: 150 mg orally twice daily

OR

apixaban: 2.5 to 5 mg orally twice daily

OR

edoxaban: 60 mg orally once daily

OR

rivaroxaban: 20 mg orally once daily

Secondary options

heparin: see local protocol for dosing guidelines, maintain activated partial thromboplastin time (aPTT) at 45-60 seconds

or

enoxaparin: 1 mg/kg subcutaneously every 12 hours

-- AND --

warfarin: 2-5 mg orally once daily initially, adjust dose according to target INR

More

Plus – treat coexisting acute disease process

Back
ACUTE
|
hemodynamically stable
Plus – 

treat coexisting acute disease process

Treatment recommended for ALL patients in selected patient group

In approximately 60% of patients, atrial flutter accompanies an acute illness and resolves with that disease process.[5]

Plus – rapid atrial pacing

Back
ACUTE
|
hemodynamically stable
|
with a permanent pacemaker or an implantable cardioverter-defibrillator or after cardiac surgery
Plus – 

rapid atrial pacing

Treatment recommended for ALL patients in selected patient group

Useful for acute conversion of atrial flutter in patients who have pacing wires in place as part of a permanent pacemaker or an implantable cardioverter-defibrillator, or for temporary atrial pacing after cardiac surgery.

ONGOING

recurrent atrial flutter or failure of elective cardioversion

1st line – catheter ablation of the cavotricuspid isthmus (CTI)

Back
ONGOING
|
recurrent atrial flutter or failure of elective cardioversion
1st line – 

catheter ablation of the cavotricuspid isthmus (CTI)

Useful in patients with atrial flutter that is symptomatic or refractory to pharmacologic rate control, patients in whom at least one antiarrhythmic drug has failed, patients who develop atrial flutter as a result of antiarrhythmic therapy for atrial fibrillation, and patients with recurrent atrial flutter.

Catheter ablation is effective at maintaining sinus rhythm in typical atrial flutter in which the CTI is a necessary part of the arrhythmic circuit. This invasive technique involves a femoral venous approach. An ablation catheter is placed at the isthmus between the inferior vena cava and the tricuspid annulus using either fluoroscopic guidance or a 3-dimensional electroanatomic mapping system. Radiofrequency energy is then applied to create a line of ablation from the tricuspid annulus to the inferior vena cava.

The success rate for treatment of typical atrial flutter is high and has been reported at 92% for the first procedure and 97% for multiple procedures.[8][41][42][43]

Atypical flutter is more difficult to ablate, particularly when associated with congenital heart disease. In such situations, consider referral to an experienced center.

Plus – anticoagulation

Back
ONGOING
|
recurrent atrial flutter or failure of elective cardioversion
Plus – 

anticoagulation

Treatment recommended for ALL patients in selected patient group

The guidelines for thromboembolic prophylaxis in atrial flutter are the same as those for atrial fibrillation.​​​​​[8][20]​​​​​​​[22]​​[45]​​​​[46]

Selection of stroke risk reduction therapy should be guided by the patient’s risk of stroke, risks of bleeding with therapy, and their individual preferences.[20]​ The AHA and ESC guidelines emphasize a risk factor-based approach using a validated clinical risk score such as the CHA2DS2-VASc score system.[8][20] [ Atrial Fibrillation CHA(2)DS(2)-VASc Score for Stroke Risk Opens in new window ] ​​​​ The CHA2DS2-VASc score is considered the most validated score; however, newer online calculators for risk scores, such as ATRIA and GARFIELD, in comparison to CHA2DS2-VASc, may modestly improve discrimination between high versus low risk and may offer potential advantages in specific populations.​[8][20]​​​​ [ Atrial Fibrillation CHA(2)DS(2)-VASc Score for Stroke Risk Opens in new window ] ​​​​ The HAS-BLED score can be used to assess bleeding risk.[20]​​ [ HAS-BLED Bleeding Risk Score Opens in new window ] ​​​​​​​

The key options for anticoagulation are a vitamin K antagonist such as warfarin, or a DOAC such as dabigatran (a direct thrombin inhibitor), rivaroxaban, apixaban, or edoxaban (direct factor Xa inhibitors). Both vitamin K antagonists and DOACs are approved as efficacious agents for stroke prevention in this patient population.[20]​ In patients who are candidates for anticoagulation and do not have either moderate-severe rheumatic mitral stenosis or mechanical heart valves, DOACs are recommended over warfarin to reduce the risk of mortality, stroke, systemic embolism and intracranial hemorrhage.[20]​ While it is reasonable to use DOACs as first-line agents or as a subsequent replacement for warfarin in patients with atrial flutter, warfarin remains the first-line therapy in patients with AF and moderate-severe rheumatic mitral stenosis or mechanical heart valves.[20]​ DOACs are recommended over warfarin in eligible patients (i.e., patients who do not have moderate-to-severe mitral stenosis or a mechanical heart valve).[20] Bridging with a parenteral anticoagulant is not necessary when initiating DOACs for this indication. DOACs do not require monitoring of anticoagulant activity; however, they must be used with caution in patients with renal impairment and a dose adjustment may be necessary.​ In the event of major bleeding, the effects of dabigatran can be reversed with idarucizumab; for reversal of apixaban, rivaroxaban or edoxaban, andexanet alfa (recombinant coagulation factor Xa) can be used.[20]​ Edoxaban should not be used in patients with a creatinine clearance >95 mL/minute because of an increased risk of ischemic stroke.​[20]​ ​Initial anticoagulation with subcutaneous LMWH or intravenous unfractionated heparin may be necessary for patients presenting acutely with atrial flutter, pending full evaluation and selection of ongoing antithrombotic therapy (recommendations vary according to duration of symptoms and timing of cardioversion).​

Warfarin is an alternative to DOAC therapy indicated for selected patients (e.g., patients with mechanical heart valves, clinically significant rheumatic mitral stenosis. Intravenous unfractionated heparin or subcutaneous LMWH should be continued until an INR of 2-3 is achieved with warfarin therapy (bridging therapy).​[20]

If there are no risk factors for stroke, aspirin either alone or in combination with clopidogrel is not recommended to reduce the risk of stroke or to prevent thromboembolic events.[20]

Anticoagulation should be established before cardioversion and is continued for at least 4 weeks after cardioversion, and may be required for longer in some patients.[20]

For more detailed anticoagulation recommendations, see New-onset atrial fibrillation.

Primary options

dabigatran etexilate: 150 mg orally twice daily

OR

apixaban: 2.5 to 5 mg orally twice daily

OR

edoxaban: 60 mg orally once daily

OR

rivaroxaban: 20 mg orally once daily

Secondary options

heparin: see local protocol for dosing guidelines, maintain activated partial thromboplastin time (aPTT) at 45-60 seconds

or

enoxaparin: 1 mg/kg subcutaneously every 12 hours

-- AND --

warfarin: 2-5 mg orally once daily initially, adjust dose according to target INR

More

1st line – beta-blocker or calcium-channel blocker

Back
ONGOING
|
recurrent atrial flutter or failure of elective cardioversion
1st line – 

beta-blocker or calcium-channel blocker

Can be useful to control the ventricular rate in patients with hemodynamically tolerated atrial flutter. Beta-blockers should be used with caution in patients with COPD or asthma, because they might provoke bronchospasm; calcium-channel blockers are preferred if chronic lung disease is also present.

Primary options

metoprolol tartrate: 25-100 mg orally (immediate-release) twice daily

OR

diltiazem: 120-360 mg/day orally (regular-release) given in 3-4 divided doses

OR

verapamil: 240-320 mg/day orally (regular-release) given in 3-4 divided doses

Plus – anticoagulation

Back
ONGOING
|
recurrent atrial flutter or failure of elective cardioversion
Plus – 

anticoagulation

Treatment recommended for ALL patients in selected patient group

The guidelines for thromboembolic prophylaxis in atrial flutter are the same as those for atrial fibrillation.​​​​​[8][20]​​​​​​​[22]​​[45]​​​​[46]

Selection of stroke risk reduction therapy should be guided by the patient’s risk of stroke, risks of bleeding with therapy, and their individual preferences.[20]​ The ​AHA and ESC guidelines emphasize a risk factor-based approach using a validated clinical risk score such as the CHA2DS2-VASc score system.[8][20] [ Atrial Fibrillation CHA(2)DS(2)-VASc Score for Stroke Risk Opens in new window ] ​​​​ The CHA2DS2-VASc score is considered the most validated score; however, newer online calculators for risk scores, such as ATRIA and GARFIELD, in comparison to CHA2DS2-VASc, may modestly improve discrimination between high versus low risk and may offer potential advantages in specific populations.​[8]​​[20] [ Atrial Fibrillation CHA(2)DS(2)-VASc Score for Stroke Risk Opens in new window ] ​​​​ The HAS-BLED score can be used to assess bleeding risk.[20]​​ [ HAS-BLED Bleeding Risk Score Opens in new window ] ​​​​​​​

The key options for anticoagulation are a vitamin K antagonist such as warfarin, or a DOAC such as dabigatran (a direct thrombin inhibitor), rivaroxaban, apixaban, or edoxaban (direct factor Xa inhibitors). Both vitamin K antagonists and DOACs are approved as efficacious agents for stroke prevention in this patient population.[20]​ In patients who are candidates for anticoagulation and do not have either moderate-severe rheumatic mitral stenosis or mechanical heart valves, DOACs are recommended over warfarin to reduce the risk of mortality, stroke, systemic embolism and intracranial hemorrhage.[20]​ While it is reasonable to use DOACs as first-line agents or as a subsequent replacement for warfarin in patients with atrial flutter, warfarin remains the first-line therapy in patients with AF and moderate-severe rheumatic mitral stenosis or mechanical heart valves.[20]​ DOACs are recommended over warfarin in eligible patients (i.e., patients who do not have moderate-to-severe mitral stenosis or a mechanical heart valve).[20]​ DOACs are the preferred agents for ongoing anticoagulant therapy; examples include dabigatran (a direct thrombin inhibitor), and apixaban, edoxaban, or rivaroxaban (direct factor Xa inhibitors).[8][20]​​​​​​​​​​​​ Bridging with a parenteral anticoagulant is not necessary when initiating DOACs for this indication. DOACs do not require monitoring of anticoagulant activity; however, they must be used with caution in patients with renal impairment and a dose adjustment may be necessary.​[20]​ In the event of major bleeding, the effects of dabigatran can be reversed with idarucizumab; for reversal of apixaban, or rivaroxaban or edoxaban, andexanet alfa (recombinant coagulation factor Xa) can be used.[20]​ DOACS are not recommended in patients with mechanical heart valves.[8][20]​​​​​​​​ Edoxaban should not be used in patients with a creatinine clearance >95 mL/minute because of an increased risk of ischemic stroke.[20]​ ​Initial anticoagulation with subcutaneous LMWH or intravenous unfractionated heparin may be necessary for patients presenting acutely with atrial flutter, pending full evaluation and selection of ongoing antithrombotic therapy (recommendations vary according to duration of symptoms and timing of cardioversion).[20]

Warfarin is an alternative to DOAC therapy indicated for selected patients (e.g., patients with mechanical heart valves, clinically significant rheumatic mitral stenosis, or severe renal impairment). Intravenous unfractionated heparin or subcutaneous LMWH should be continued until an INR of 2-3 is achieved with warfarin therapy (bridging therapy).​[20]

If there are no risk factors for stroke, aspirin either alone or in combination with clopidogrel is not recommended to reduce the risk of stroke or to prevent thromboembolic events.[20]

Anticoagulation should be established before cardioversion and is continued for at least 4 weeks after cardioversion, and may be required for longer in some patients.[20]

For more detailed anticoagulation recommendations, see New-onset atrial fibrillation.

Primary options

dabigatran etexilate: 150 mg orally twice daily

OR

apixaban: 2.5 to 5 mg orally twice daily

OR

edoxaban: 60 mg orally once daily

OR

rivaroxaban: 20 mg orally once daily

Secondary options

heparin: see local protocol for dosing guidelines, maintain activated partial thromboplastin time (aPTT) at 45-60 seconds

or

enoxaparin: 1 mg/kg subcutaneously every 12 hours

-- AND --

warfarin: 2-5 mg orally once daily initially, adjust dose according to target INR

More

Consider – antiarrhythmic therapy

Back
ONGOING
|
recurrent atrial flutter or failure of elective cardioversion
Consider – 

antiarrhythmic therapy

Treatment recommended for SOME patients in selected patient group

Can be useful to maintain sinus rhythm in patients with symptomatic recurrent atrial flutter.

Drug choice depends on the presence or absence of underlying heart disease and any comorbidities. Options include amiodarone, dofetilide, and sotalol. Flecainide or propafenone must be given with a rate-control drug and should only be considered in patients who do not have structural or ischemic heart disease.

Amiodarone is less proarrhythmogenic than other antiarrhythmics and relatively safe in patients with structural heart disease.[44]

Dofetilide is contraindicated in patients with long QT syndrome, QT prolongation, renal failure, and torsade de pointes. Continuous ECG monitoring is required during administration and for at least 3 days (or 12 hours after conversion to normal sinus rhythm, whichever is greater) after completion of therapy. It should only be initiated by a physician experienced in its use.

Sotalol has both class II beta-blocking and class III properties, and thus provides rate control. It is contraindicated in patients with renal failure or creatinine clearance <40 mL/minute.

Antiarrhythmic dosing follows atrial fibrillation guidelines, as not many of the studies looked at atrial flutter separately.[4]​​

Primary options

amiodarone: 100-400 mg orally once daily

OR

dofetilide: dose depends on QTc and renal function; consult specialist for guidance on dose

OR

sotalol: 80-160 mg orally twice daily

OR

flecainide: 50-150 mg orally twice daily

OR

propafenone: 150-300 mg orally (immediate-release) three times daily

back arrow

Choose a patient group to see our recommendations

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

Use of this content is subject to our disclaimer