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Shown below is an algorithm summarizing the therapeutic approach to [[atrial flutter]].<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher =  | date =  | accessdate = 15 August 2013 }}</ref>
Shown below is an algorithm summarizing the therapeutic approach to [[atrial flutter]].<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher =  | date =  | accessdate = 15 August 2013 }}</ref>
{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | A01 | | | | | | | | | | |A01=[[Atrial flutter]] }}
{{familytree | | | | | | | A01 | | | | | | | | | | |A01=[[Atrial flutter]]</div> }}
{{familytree | | | |,|-|-|-|^|-|-|-|.| | | | | | | | }}
{{familytree | | | |,|-|-|-|^|-|-|-|.| | | | | | | | }}
{{familytree | | | B01 | | | | | | B02 | | | | | | |B01=Unstable |B02=Stable }}
{{familytree | | | B01 | | | | | | B02 | | | | | | |B01=Unstable |B02=Stable }}
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<tr><td>▸ '''''Conversion'''''</td><td> ▸ '''''DC cardioversion ([[ACC AHA guidelines classification scheme|class I, level of evidence C]])'''''</td></tr>
<tr><td>▸ '''''Conversion'''''</td><td> ▸ '''''DC cardioversion ([[ACC AHA guidelines classification scheme|class I, level of evidence C]])'''''</td></tr>
<tr><td>▸ '''''Rate control'''''</td><td>▸ '''''[[Beta blockers]] ([[ACC AHA guidelines classification scheme|class IIa, level of evidence C]])'''''<br> or <br>▸ '''''[[Verapamil]] or [[diltiazem]] ([[ACC AHA guidelines classification scheme|class IIa, level of evidence C]])'''''<br> or <br>▸ '''''[[Digitalis]] ([[ACC AHA guidelines classification scheme|class IIb, level of evidence C]])'''''<br> or <br>▸ '''''[[Amiodarone]] ([[ACC AHA guidelines classification scheme|class IIb, level of evidence C]])'''''</td></tr>
<tr><td>▸ '''''Rate control'''''</td><td>▸ '''''[[Beta blockers]] ([[ACC AHA guidelines classification scheme|class IIa, level of evidence C]])'''''<br> or <br>▸ '''''[[Verapamil]] or [[diltiazem]] ([[ACC AHA guidelines classification scheme|class IIa, level of evidence C]])'''''<br> or <br>▸ '''''[[Digitalis]] ([[ACC AHA guidelines classification scheme|class IIb, level of evidence C]])'''''<br> or <br>▸ '''''[[Amiodarone]] ([[ACC AHA guidelines classification scheme|class IIb, level of evidence C]])'''''</td></tr>
</table></div>|C02=<div style="float: left; text-align: left; padding:1em;"> ❑ Administer anticoagulation therapy based on the risk of stroke, if total duration of flutter > 48 hours <br> Rate control therapy as shown in table below:
</table></div>|C02=<div style="float: left; text-align: left; width:30em; padding:1em;"> ❑ Administer anticoagulation therapy based on the risk of stroke, if total duration of flutter > 48 hours <br> Rate control therapy as shown in table below:


<table class="wikitable">
<table class="wikitable">
<tr><td>▸ '''''Rate control'''''</td><td>▸ '''''[[Beta blockers]] ([[ACC AHA guidelines classification scheme|class IIa, level of evidence C]])'''''<br> or <br>▸ '''''[[Verapamil]] or [[diltiazem]] ([[ACC AHA guidelines classification scheme|class IIa, level of evidence C]])'''''<br> or <br>▸ '''''[[Digitalis]] ([[ACC AHA guidelines classification scheme|class IIb, level of evidence C]])'''''<br> or <br>▸ '''''[[Amiodarone]] ([[ACC AHA guidelines classification scheme|class IIb, level of evidence C]])'''''</td></tr>
<tr><td>▸ '''''Rate control'''''</td><td>▸ '''''[[Beta blockers]] ([[ACC AHA guidelines classification scheme|class IIa, level of evidence C]])'''''<br> or <br>▸ '''''[[Verapamil]] or [[diltiazem]] ([[ACC AHA guidelines classification scheme|class IIa, level of evidence C]])'''''<br> or <br>▸ '''''[[Digitalis]] ([[ACC AHA guidelines classification scheme|class IIb, level of evidence C]])'''''<br> or <br>▸ '''''[[Amiodarone]] ([[ACC AHA guidelines classification scheme|class IIb, level of evidence C]])'''''</td></tr>
</table> <br><br> ''THEN'' <br><br> ❑ Attempt conversion as shown in table below: <br>
</table> </div> }}
 
{{familytree | | | |!| | | | | | | |!| | | | | | | | | }}
{{familytree | | | |!| | | | | | | G01 | | | | | | | |G01=<div style="float: left; text-align: left; padding:1em;"> ❑ Attempt conversion as shown in table below: <br>
<table class="wikitable">
<table class="wikitable">
<tr><td>▸ '''''Conversion'''''</td><td>▸ '''''Atrial or transesophageal pacing ([[ACC AHA guidelines classification scheme|class I, level of evidence A]])'''''<br> or <br>▸ '''''DC cardioversion ([[ACC AHA guidelines classification scheme|class I, level of evidence C]])'''''<br> or <br>▸ '''''Ibutilide ([[ACC AHA guidelines classification scheme|class IIa, level of evidence A]])'''''<br> or <br>▸ '''''Flecainide ([[ACC AHA guidelines classification scheme|class IIb, level of evidence A]])'''''<br> or <br>▸ '''''Propafenone ([[ACC AHA guidelines classification scheme|class IIb, level of evidence A]])'''''<br> or <br>▸ '''''Sotalol ([[ACC AHA guidelines classification scheme|class IIb, level of evidence C]])'''''<br> or <br>▸ '''''Procainamide ([[ACC AHA guidelines classification scheme|class IIb, level of evidence A]])'''''<br> or <br>▸ '''''Amiodarone ([[ACC AHA guidelines classification scheme|class IIb, level of evidence C]])''''' </td></tr>
<tr><td>▸ '''''Conversion'''''</td><td>▸ '''''Atrial or transesophageal pacing ([[ACC AHA guidelines classification scheme|class I, level of evidence A]])'''''<br> or <br>▸ '''''DC cardioversion ([[ACC AHA guidelines classification scheme|class I, level of evidence C]])'''''<br> or <br>▸ '''''Ibutilide ([[ACC AHA guidelines classification scheme|class IIa, level of evidence A]])'''''<br> or <br>▸ '''''Flecainide ([[ACC AHA guidelines classification scheme|class IIb, level of evidence A]])'''''<br> or <br>▸ '''''Propafenone ([[ACC AHA guidelines classification scheme|class IIb, level of evidence A]])'''''<br> or <br>▸ '''''Sotalol ([[ACC AHA guidelines classification scheme|class IIb, level of evidence C]])'''''<br> or <br>▸ '''''Procainamide ([[ACC AHA guidelines classification scheme|class IIb, level of evidence A]])'''''<br> or <br>▸ '''''Amiodarone ([[ACC AHA guidelines classification scheme|class IIb, level of evidence C]])''''' </td></tr>
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<table class="wikitable">
<table class="wikitable">
<tr class="v-firstrow"><th></th><th></th></tr>
<tr><td>▸ '''''First episode and well-tolerated atrial flutter'''''</td><td>▸ '''''Cardioversion alone ([[ACC AHA guidelines classification scheme|class I, level of evidence B]])''''' <br> or <br> ▸ '''''Catheter ablation ([[ACC AHA guidelines classification scheme|class IIa, level of evidence B]])'''''</td></tr>
<tr><td>▸ '''''First episode and well-tolerated atrial flutter'''''</td><td>▸ '''''Cardioversion alone ([[ACC AHA guidelines classification scheme|class I, level of evidence B]])''''' <br> or <br> ▸ '''''Catheter ablation ([[ACC AHA guidelines classification scheme|class IIa, level of evidence B]])'''''</td></tr>
<tr><td>▸ '''''Recurrent and well-tolerated atrial flutter'''''</td><td>▸ '''''Catheter ablation([[ACC AHA guidelines classification scheme|class I, level of evidence B]])'''''<br> or <br>▸ '''''Dofetilide ([[ACC AHA guidelines classification scheme|class IIa, level of evidence C]])'''''<br> or <br>▸ '''''Amiodarone ([[ACC AHA guidelines classification scheme|class IIb, level of evidence C]]) <br>or<br> Sotalol <br>or<br> Flecainide <br>or<br> Quinidine <br>or<br> Propafenone <br>or<br> Procainamide <br>or<br> Disopyramide''''' </td></tr>
<tr><td>▸ '''''Recurrent and well-tolerated atrial flutter'''''</td><td>▸ '''''Catheter ablation([[ACC AHA guidelines classification scheme|class I, level of evidence B]])'''''<br> or <br>▸ '''''Dofetilide ([[ACC AHA guidelines classification scheme|class IIa, level of evidence C]])'''''<br> or <br>▸ '''''Amiodarone ([[ACC AHA guidelines classification scheme|class IIb, level of evidence C]]) <br>or<br> Sotalol <br>or<br> Flecainide <br>or<br> Quinidine <br>or<br> Propafenone <br>or<br> Procainamide <br>or<br> Disopyramide''''' </td></tr>
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<tr><td>▸ '''''Atrial flutter appearing after use of class Ic agents or amiodarone for treatment of AF'''''</td><td>▸ '''''Catheter ablation ([[ACC AHA guidelines classification scheme|class I, level of evidence B]])''''' <br> or <br>▸ '''''Stop current drug and use another ([[ACC AHA guidelines classification scheme|class IIa, level of evidence C]])'''''</td></tr>
<tr><td>▸ '''''Atrial flutter appearing after use of class Ic agents or amiodarone for treatment of AF'''''</td><td>▸ '''''Catheter ablation ([[ACC AHA guidelines classification scheme|class I, level of evidence B]])''''' <br> or <br>▸ '''''Stop current drug and use another ([[ACC AHA guidelines classification scheme|class IIa, level of evidence C]])'''''</td></tr>
<tr><td>▸ '''''Symptomatic non–CTI-dependent flutter after failed antiarrhythmic drug therapy'''''</td><td>'''''Catheter ablation ([[ACC AHA guidelines classification scheme|class IIa, level of evidence B]])'''''</td></tr>
<tr><td>▸ '''''Symptomatic non–CTI-dependent flutter after failed antiarrhythmic drug therapy'''''</td><td>'''''Catheter ablation ([[ACC AHA guidelines classification scheme|class IIa, level of evidence B]])'''''</td></tr>
</table>----
</table>
----
❑ Consider catheter ablation if antiarrhythmic therapy fails </div>}}
❑ Consider catheter ablation if antiarrhythmic therapy fails </div>}}
{{familytree/end}}
{{familytree/end}}

Revision as of 20:56, 11 March 2014

Therapeutic Approach

Shown below is an algorithm summarizing the therapeutic approach to atrial flutter.[1]

 
 
 
 
 
 
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)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ 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 therapyCatheter ablation (class IIa, level of evidence B)
❑ Consider catheter ablation if antiarrhythmic therapy fails
 
 
 
 
 
 
 
 
 
 
  1. ↑ "ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary". Retrieved 15 August 2013.
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