eMedicine Specialties > Cardiology > Arrhythmias

Atrial Flutter: Follow-up

Author: Lawrence Rosenthal, MD, PhD, Associate Professor of Medicine, Director, Section of Cardiac Electrophysiology and Pacing, Fellowship Director of Clinical Cardiac Electrophysiology, Department of Internal Medicine, Division of Cardiovascular Medicine, University of Massachusetts Memorial Medical Center
Coauthor(s): Cynthia Anne Ennis, DO, Electrophysiology Fellow, University of Massachusetts Medical Center
Contributor Information and Disclosures

Updated: Aug 3, 2009

Follow-up

Further Inpatient Care

  • Consider catheter-based ablation as first-line therapy in patients with type I typical atrial flutter if they are reasonable candidates. Ablation is usually done as an elective procedure; however, it can be done when the patient is in atrial flutter as well.
  • Given the high success rate and low complication rate, radiofrequency ablation is superior to medical therapy.
  • For atrial flutter of less than 48 hours in duration, attempt cardioversion as soon as possible. Postconversion anticoagulation is usually unnecessary, although data from TEE studies indicate that postconversion anticoagulation a reasonable option.
  • For episodes of atrial flutter of uncertain duration or greater than 48 hours, begin anticoagulation therapy. If cardioversion is needed sooner, anticoagulate patients with intravenous heparin and perform TEE as close to the time of cardioversion as possible. Patients still require anticoagulation for at least 4 weeks after cardioversion.
  • If thrombus is observed or suspected based on TEE findings, delay cardioversion. Rate control and therapeutic anticoagulation is required for a minimum of 4 weeks.
  • In patients who are not candidates for catheter-based ablation, rate and rhythm control strategies should be considered. The risk of proarrhythmia is probably greatest during the first 24-48 hours after the initiation of antiarrhythmics and drugs such as ibutilide, sotalol, and dofetilide should be initiated in an inpatient setting. Pause-dependent torsades de pointes can occur after conversion to sinus rhythm.

Further Outpatient Care

Closely monitor the patient's anticoagulation therapy, with a target INR of 2-3. Take special care when additional medications (including antibiotics) are added because they may cause dramatic alterations in INR values.

Inpatient & Outpatient Medications

  • Anticoagulant therapy (ie, heparin and/or warfarin) is indicated, especially when the onset of atrial flutter is of more than 48 hours' duration or is uncertain.
    • Patients need to maintain a therapeutic INR for 3 weeks prior to conversion and for at least 4 weeks after conversion to sinus rhythm.
    • Long-term anticoagulation is recommended for patients with chronic atrial flutter.
    • Anticoagulants are used to decrease thromboembolic complications.
  • Preferred medications that slow AV node conduction include beta-blockers (eg, atenolol, metoprolol, propranolol) and calcium channel blockers (eg, verapamil, diltiazem).
    • These medications are used to control ventricular rates.
    • Also use these medications in patients who are taking class IA or IC antiarrhythmic drugs (to prevent rapid ventricular response, which can occur when the atrial rate is slowed).
  • Antiarrhythmic drugs are indicated for the termination of acute episodes or the prevention of recurrent episodes.
    • For atrial flutter, electrical cardioversion is effective and usually requires less energy than for atrial fibrillation.
    • Catheter ablation offers a potential cure and is safer long-term use of an antiarrhythmic agent.

Complications

The major potential complication with atrial flutter (or atrial fibrillation) is neurologic insult, either transient ischemic attack or stroke. This risk can be minimized with proper anticoagulation. Consider patients with common type I atrial flutter for catheter ablation to eliminate the need for long-term anticoagulation and antiarrhythmic medications.

Prognosis

  • Atrial flutter itself is not considered a life-threatening arrhythmia; however, uncontrolled ventricular rates can lead to impaired ventricular function. Additionally, patients with Wolff-Parkinson-White syndrome can develop life-threatening ventricular responses. Consider these patients for catheter ablation of their accessory bypass tract. Data from the Framingham study suggest that patients with atrial fibrillation do not live as long as patients without atrial fibrillation (ie, controls). No data are available on atrial flutter.
  • The prognosis for patients with Type I atrial flutter who undergo catheter ablation is excellent, with a very low recurrence rate. The picture is not as clear for patients with both atrial flutter and atrial fibrillation. Some reports have documented fewer episodes of atrial fibrillation after successful flutter ablation, while others have not. Atrial fibrillation is thought to possibly be more responsive to antiarrhythmic agents after atrial flutter has been eliminated.
  • Numerous reports indicate that patients with atrial fibrillation who are given class IC antiarrhythmic agents may convert to atrial flutter with faster ventricular rates. Thus, patients receiving type IC agents (flecainide) should also receive an AV nodal blocking drug such as a beta-blocker or calcium channel blocker.

Patient Education

  • Patient education regarding medications and diet is important.
  • Patients taking warfarin should avoid major changes in their diet unless consulting with their providers. Recall that warfarin inhibits vitamin K synthesis and that sources of vitamin K are green leafy vegetables. A sudden change to a diet high in vitamin K may increase the requirements for warfarin.
  • For excellent patient education resources, visit eMedicine's Heart Center and Stroke Center. Also, see eMedicine's patient education articles Atrial Flutter, Heart Rhythm Disorders, Stroke, Supraventricular Tachycardia, and Palpitations.

Miscellaneous

Medicolegal Pitfalls

Because data suggest that patients with atrial flutter may be at similar risk for neurologic events as patients with atrial fibrillation, considering anticoagulation in this patient population (at least until sinus rhythm is maintained) is a wise decision.

 


More on Atrial Flutter

Overview: Atrial Flutter
Differential Diagnoses & Workup: Atrial Flutter
Treatment & Medication: Atrial Flutter
Follow-up: Atrial Flutter
Multimedia: Atrial Flutter
References
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Further Reading

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Keywords

atrial flutter, atrial flutter treatment, arrhythmia, atrial fibrillation, supraventricular tachycardia, SVT, congestive heart failure, CHF, ventricular tachycardia, VT, ventricular fibrillation, VF, coronary artery disease, CAD, thromboembolic stroke, percutaneous catheter-based techniques, congenital cardiac anomalies, hypertensive heart disease, chronic obstructive pulmonary disease, COPD, thromboembolic complications, cardiomyopathy, hypoxia, thyrotoxicosis, pheochromocytoma

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Contributor Information and Disclosures

Author

Lawrence Rosenthal, MD, PhD, Associate Professor of Medicine, Director, Section of Cardiac Electrophysiology and Pacing, Fellowship Director of Clinical Cardiac Electrophysiology, Department of Internal Medicine, Division of Cardiovascular Medicine, University of Massachusetts Memorial Medical Center
Lawrence Rosenthal, MD, PhD is a member of the following medical societies: American College of Cardiology, American Heart Association, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Cynthia Anne Ennis, DO, Electrophysiology Fellow, University of Massachusetts Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Alan D Forker, MD, Professor of Medicine, Program Director of Cardiovascular Fellowship, University of Missouri at Kansas City School of Medicine; Director, Outpatient Lipid Diabetes Research Center, MidAmerica Heart Institute of St Luke's Hospital
Alan D Forker, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, American Society of Hypertension, and Phi Beta Kappa
Disclosure: Research Grant Grant/research funds Hospital contracts to do research; I am a hospital employee with no personal profit; Speakers Bureau Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Brian Olshansky, MD, Professor of Medicine, Department of Internal Medicine, University of Iowa College of Medicine
Brian Olshansky, MD is a member of the following medical societies: American Autonomic Society, American College of Cardiology, American College of Chest Physicians, American College of Physicians, American College of Sports Medicine, American Federation for Clinical Research, American Heart Association, Cardiac Electrophysiology Society, Heart Rhythm Society, and New York Academy of Sciences
Disclosure: Guidant/Boston Scientific Honoraria Speaking and teaching; Medtronic Honoraria Speaking and teaching; Guidant/Boston Scientific Consulting fee Consulting; Reliant Grant/research funds Other; Novartis Honoraria Speaking and teaching; Novartis Consulting fee Consulting

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Jeffrey N Rottman, MD, Professor of Medicine and Pharmacology, Director, Clinical Cardiac Electrophysiology Fellowship Program, Vanderbilt University School of Medicine; Chief, Department of Cardiology, Nashville Veterans Affairs Medical Center
Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association and North American Society of Pacing and Electrophysiology (NASPE)
Disclosure: Nothing to disclose.

 
 
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