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Atrial flutter

What's new

Updated 2023 ACC/AHA/ACCP/HRS guidelines for the management of atrial flutter.

Background

Overview

Definition
Atrial flutter is a supraventricular arrhythmia characterized by rapid, regular atrial contractions, primarily confined to the right atrium.
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Pathophysiology
The pathophysiology of atrial flutter involves the formation of a reentrant circuit, often around the tricuspid valve or along the RA wall. This circuit results in a rapid and regular atrial rhythm. Abnormal intraatrial conduction, slow conduction paths, and areas of low voltage in the atria can contribute to the initiation and maintenance of these reentrant circuits.
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Epidemiology
The prevalence of idiopathic neonatal atrial flutter in Europe is estimated at 1.5 per 100,000 population.
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Disease course
The clinical features of atrial flutter often include palpitations, dyspnea, and chest discomfort. However, the diagnosis is often confirmed through a 12-lead ECG or an electrophysiology study and mapping. Complications can include stroke, HF, thromboembolism, and progression to AF.
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Prognosis and risk of recurrence
The prognosis of atrial flutter can be influenced by several factors. The presence of underlying heart disease can complicate the condition and lead to poorer outcomes. There is a risk of progression to AF.
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Guidelines

Key sources

The following summarized guidelines for the management of atrial flutter are prepared by our editorial team based on guidelines from the American Heart Association (AHA/HRS/ACC/ACCP 2024), the European Society of Cardiology (ESC/EACTS 2021), the Canadian Cardiovascular Society (CCS/CHRS 2020), the European Society of Cardiology (ESC 2020,2018), the Canadian Cardiovascular Society (CCS 2018), the Latin American Heart Rhythm Society (SOLAECE/ECAS/APHRS/EHRA/HRS 2017), ...
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Medical management

Rate control, acute
As per ESC 2020 guidelines:
Consider administering IV β-blockers or nondihydropyridine CCBs (verapamil or diltiazem) for control of rapid ventricular rate in hemodynamically stable patients with macroreentrant atrial arrhythmia.
C
Consider administering IV amiodarone if the above agents are not available or desirable.
C
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  • Rate control (long-term)

  • Rhythm control (acute)

  • Rhythm control (long-term)

  • Antithrombotic therapy

Therapeutic procedures

Electrical cardioversion
As per ESC 2020 guidelines:
Perform synchronized direct cuttent cardioversion in hemodynamically unstable patients with macroreentrant atrial arrhythmia.
B
Perform low-energy (100 J biphasic) electrical cardioversion in hemodynamically stable patients with macroreentrant atrial arrhythmia.
B

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  • Atrial pacing

  • Catheter ablation

  • Catheter ablation (ECS)

  • Atrioventricular nodal ablation

Perioperative care

Pericardioversion anticoagulation: as per ACC/ACCP/AHA/HRS 2024 guidelines, initiate anticoagulant therapy in patients with atrial flutter according to the same risk profile used for AF.
B
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Surgical interventions

Surgical ablation: as per ACC/AHA/HRS 2016 guidelines, consider performing surgical ablation of atrial flutter in adult patients with congenital heart disease undergoing planned surgical repair.
C

Specific circumstances

Pregnant patients: as per ESC 2020 guidelines, consider administering IV ibutilide for termination of atrial flutter in pregnant patients.
C

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  • Patients with congenital heart disease

  • Patients with pulmonary hypertension

Follow-up and surveillance

Follow-up: as per CCS/CHRS 2020 guidelines, monitor patients after atrial flutter ablation for the occurrence of AF with opportunistic screening conducted at the time of medical encounters.
B