Atrial flutter: Pharmacologic treatment

Initial treatment of atrial flutter targets the rate control (which is frequently ~150 BPM). Drugs of choice include beta blockers such as esmolol (0.5 mg/kg IV bolus followed by 50-300 ucg/kg/min) and propranolol, or calcium channel blockers such as verapamil (5-10 mg IV) or diltiazem. Beta blockers and CCB are effective in prophylactic prevention of atrial flutter after postoperative thoracic or cardiac surgery.

If a patient is hemodynamically unstable and/or has an excessively rapid ventricular rate you may consider an antiarrhthmic drug or synchronized DC cardioversion. If synchronized DC cardioversion is utilized in a non-emergent setting, the provider must be certain that the atrial flutter is new-onset, that a patient does not have thrombosis in the heart via echo, or that the patient has been adequately anticoagulated in order to prevent a thromboembolic event.

Ibutilide, a class III antiarrhythmic (Corvert, 1 mg in 10 mL saline infused slowly over 10 minutes) is effective in converting new-onset atrial flutter patients to normal sinus rhythm 90% of the time. It may be repeated once, but the provider should be aware it has a potential risk of inducing torsades de pointes, so the patient needs to be monitored carefully for 4-8 hours after drug administration. Amiodarone (150 mg IV loading dose infused over 10 minutes, followed by 1 mg/min infusion for 6 hours, a 0.5-mg/min infusion for 18 hours, and then a reduced IV dose or oral dose) is also effective in converting atrial flutter to normal sinus ryhthm. Procainamide is another lesser used choice after rate is controlled.

Atrial Flutter

• Stable: esmolol, diltiazem for rate control
• Hemodynamically Untable: synchronized cardioversion (relatively high doses; rule out clot via TEE)