Atrial Flutter Guidelines

Updated: Nov 18, 2019
  • Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jeffrey N Rottman, MD  more...
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Guidelines Summary

In August 2019, the European Society of Cardiology (ESC) in collaboration with the Association for European Paediatric and Congenital Cardiology (AEPC) released recommendations on the management of supraventricular tachycardia. [32, 33] Previous related guidelines include, but are not limited to, the 2015 American College of Cardiology, American Heart Association, and Heart Rhythm Society (ACC/AHA/HRS) guidelines for the management of supraventricular tachycardia which includes algorithms for both acute and ongoing treatment of atrial flutter. [14] These guidelines are summarized in the following sections.


2019 ESC/AEPC Guidelines for the Management of Supraventricular Tachycardia

Supraventricular Tachycardia Clinical Practice Guidelines (2019)

Several changes from the previous guidelines (2003) include revised drug grades as well as medications that are no longer considered, and changes to ablation techniques and indications. [32, 33]

Table. Medications, Strategies, and Techniques Specified or Not Mentioned in the 2019 Guidelines (Open Table in a new window)

Type of Tachycardia

Treatment (Grade)

Not Mentioned in 2019 Guidelines

Narrow QRS tachycardias

Verapamil and diltiazem; beta-blockers (now all are grade IIa)

Amiodarone, digoxin

Wide QRS tachycardias

Procainamide, adenosine (both grade IIa); amiodarone (IIb)

Sotalol, lidocaine

Inappropriate sinus tachycardia

Beta-blockers (IIa)

Verapamil/diltiazem, catheter ablation

Postural orthostatic tachycardia syndrome

Salt and fluid intake (IIb)

Head-up tilt sleep, compression stockings, selective beta-blockers, fludrocortisone, clonidine, methylphenidate, fluoxetine, erythropoietin, ergotaminel octreotide, phenobarbitone

Focal atrial tachycardia

Acute: beta-blockers (IIa); flecainide/propafenone, amiodarone (IIb)

Acute: procainamide, sotalol, digoxin

Chronic: beta-blockers; verapamil and diltiazem (all IIa)

Chronic: amiodarone, sotalol, disopyramide

Atrial flutter

Acute: ibutilide (I); verapamil and diltiazem, beta-blockers (all IIa); atrial or transesophageal pacing (IIb); flecainide/propafenone (III)

Acute: digitalis


Chronic: dofetilide, sotalol, flecainide, propafenone, procainamide, quinidine, disopyramide

Atrioventricular nodal re-entrant tachycardia (AVNRT)


Acute: amiodarone, sotalol, flecainide, propafenone

Chronic: verapamil and diltiazem; beta-blockers (all IIa)

Chronic: amiodarone, sotalol, flecainide, propafenone, “pill-in-the-pocket” approach

Atrioventricular re-entrant tachycardia (AVRT)

Beta-blockers (IIa); flecainide/propafenone (IIb)

Amiodarone, sotalol, “pill-in-the-pocket” approach

SVT in pregnancy

Verapamil (IIa); catheter ablation (IIa when fluoroless ablation is available)

Sotalol, propafenone, quinidine, procainamide

Adapted from Brugada J, Katritsis DG, Arbelo E, et al, for the ESC Scientific Document Group. 2019 ESC Guidelines for the management of patients with supraventricular tachycardia. The Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J. 2019 Aug 31;ehz467.

2019 New Recommendations

For detailed recommendations on specific types of SVTs, please consult the original guidelines as listed under the references.

Class I (recommended or indicated)

For conversion of atrial flutter: Intravenous (IV) ibutilide, or IV or oral (PO) (in-hospital) dofetilide

For termination of atrial flutter (when an implanted pacemaker or defibrillator is present): High-rate atrial pacing

For asymptomatic patients with high-risk features (eg, shortest pre-excited RR interval during atrial fibrillation [SPERRI] ≤250 ms, accessory pathway [AP] effective refractory period [ERP] ≤250 ms, multiple APs, and an inducible AP-mediated tachycardia) as identified on electrophysiology testing (EPS) using isoprenaline: Catheter ablation

For tachycardia responsible for tachycardiomyopathy that cannot be ablated or controlled by drugs: Atrioventricular nodal ablation followed by pacing (“ablate and pace”) (biventricular or His-bundle pacing)

First trimester of pregnancy: Avoid all antiarrhythmic drugs, if possible

Class IIa (should be considered)

Symptomatic patients with inappropriate sinus tachycardia: Consider ivabradine alone or with a beta-blocker

Atrial flutter without atrial fibrillation: Consider anticoagulation (initiation threshold not yet established)

Asymptomatic preexcitation: Consider EPS for risk stratification

Asymptomatic preexcitation with left ventricular dysfunction due to electrical dyssynchrony: Consider catheter ablation

Class IIb (may be considered)

Acute focal atrial tachycardia: Consider IV ibutilide

Chronic focal atrial tachycardia: Consider ivabradine with a beta-blocker

Postural orthostatic tachycardia syndrome: Consider ivabradine

Asymptomatic preexcitation: Consider noninvasive assessment of the AP conducting properties

Asymptomatic preexcitation with low-risk AP at invasive/noninvasive risk stratification: Consider catheter ablation

Prevention of SVT in pregnant women without Wolff-Parkinson-White syndrome: Consider beta-1 selective blockers (except atenolol) (preferred) or verapamil

Prevention of SVT in pregnant women without Wolff-Parkinson-White syndrome and without ischemic or structural heart disease: Consider flecainide or propafenone

Class III (not recommended)

IV amiodarone is not recommended for preexcited atrial fibrillation.


2015 ACC/AHA/HRS Guideline for the Management of Supraventricular Tachycardia

Management of Acute Atrial Flutter

Hemodynamically unstable patients [14]

For rhythm control, synchronized cardioversion is recommended. (Class I recommendation)

For rate control, intravenous (IV) amiodarone is recommended. (Class IIa recommendation)

Hemodynamically stable patients [14]

For rhythm control, the following are recommended (all class I recommendations):

  • Synchronized cardioversion, oral dofetilide, IV ibutilide, and/or rapid atrial pacing
  • Rapid atrial pacing in patients who have pacing wires in place as part of a permanent pacemaker or implantable cardioverter-defibrillator or for temporary atrial pacing after cardiac surgery
  • Elective synchronized cardioversion

Note that synchronized cardioversion or rapid atrial pacing is not appropriate for rhythms that break or spontaneously recur.

For rate control, beta blockers, diltiazem, or verapamil is recommended. (Class I recommendation) [14] IV amiodarone is recommended when beta blockers are contraindicated. (Class IIa recommendation)

Management of Ongoing Atrial Flutter

Rate control [14]

Administer beta blockers, diltiazem, or verapamil. (Class I recommendation)

  • Beta blockers are generally preferred in patients with heart failure.
  • Given the potential for accelerated ventricular rates degenerating to ventricular fibrillation, beta blockers, diltiazem, and verapamil should be avoided in patients with pre-excited atrial flutter.

Rhythm control [14]

After assuring adequate anticoagulation or excluding left atrial thrombus by transesophageal echocardiography (TEE) before conversion, catheter ablation is preferred to long-term pharmacologic therapy for cavotricuspid isthmus (CTI)-dependent atrial flutter.(Class I recommendation) Other indications for catheter ablation include the following:

  • For non–CTI-dependent flutter after failure of at least one antiarrhythmic agent (class I)
  • For CTI-dependent atrial flutter that occurs as the result of flecainide, propafenone, or amiodarone used to treat atrial fibrillation (AF) (class IIa) or as primary therapy, before antiarrhythmic drugs, after carefully weighing the potential risks and benefits of treatment options (class IIa)
  • For patients undergoing catheter ablation of AF who also have a history of CTI-dependent atrial flutter (class IIa)
  • For asymptomatic patients with recurrent atrial flutter (class IIb)

Antiarrhythmic agents can be considered in patients with symptomatic, recurrent atrial flutter, with the drug choice depending on the patient's underlying heart disease and comorbidities. (Class IIa recommendation) Drug choices include the following:

  • Amiodarone
  • Dofetilide
  • Sotalol

​Flecainide or propafenone may be considered in patients without structural heart disease or ischemic heart disease who have symptomatic recurrent atrial flutter. (Class IIb recommendation)

Prevention of Thromboembolic Complications

The 2015 ACC/AHA/HRS guidelines [14] concur with the 2012 American College of Chest Physicians (ACCP) thrombosis prevention recommendation [22] that the anticoagulation strategy used for AF be followed for patients with atrial flutter. Select, specific ACCP recommendation are summarized below. [22]

No therapy for patients at low risk of stroke (eg, CHADS2 score = 0). For patients who choose therapy, use aspirin (75 mg to 325 mg daily) rather than oral anticoagulation or combination therapy with aspirin and clopidogrel. (Grade 2B)

For patients at intermediate risk of stroke (eg, CHADS2 score = 1), oral anticoagulation is preferred to no treatment (Grade 1B), aspirin daily, or combination therapy with aspirin and clopidogrel. (Grade 2B)

For patients at high risk of stroke (eg, CHADS2 score ≥2), oral anticoagulation is preferred to no treatment (Grade 1A), aspirin daily, or combination therapy with aspirin and clopidogrel. (Grade 1B)

For oral anticoagulation, use dabigatran 150 mg twice daily rather than adjusted-dose vitamin K antagonist (VKA) therapy (target INR range, 2.0-3.0) (Grade 2B)

Patients who are unsuitable for or choose not to take an oral anticoagulant (for reasons other than concerns about major bleeding), use combination therapy with aspirin and clopidogrel. (Grade 1B)

In general, when atrial flutter persists for longer than 48 hours, 4 weeks of adequate anticoagulation must be provided or the absence of thrombus on TEE documented before attempting cardioversion to sinus rhythm. Postconversion anticoagulation is recommended for a minimum of 4 weeks, because thromboembolic complications can occur spontaneously after cardioversion or ablation. (Grade 1B)

Use long-term anticoagulation for patients with persistent or paroxysmal atrial flutter. As with AF, keep the INR at 2-3 to optimize the therapeutic effect and minimize the risk of bleeding.