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Therapeutic Approach

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

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 I, level of evidence C) or Verapamil or diltiazem (class I, level of evidence A) 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 I, level of evidence C) or Verapamil or diltiazem (class I, level of evidence A) or Digitalis (class IIb, level of evidence C) or Amiodarone (class IIb, level of evidence C) THEN ❑ 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) Flecainide (class IIb, level of evidence A) Propafenone (class IIb, level of evidence A) Sotalol (class IIb, level of evidence C) Procainamide (class IIb, level of evidence A) Amiodarone (class IIb, level of evidence C)

❑ Assess need for therapy to prevent recurrence

❑ Administer antiarrythmic therapy to prevent recurrences ❑ Consider catheter ablation if antiarrhythmic therapy fails