|Clinical Status/Proposed Therapy||Recommendation||Classification||Level of Evidence||References|
|First episode and well-tolerated atrial flutter||Cardioversion alone||I||B||189|
|Recurrent and well-tolerated atrial flutter||Catheter ablation∗||I||B||162,163,199|
|Amiodarone, sotalol, flecainide,†‡quinidine,†‡propafenone,†‡procainamide,†‡disopyramide†‡||IIb||C||23,156,200|
|Poorly tolerated atrial flutter||Catheter ablation∗||I||B||162,163,199|
|Atrial flutter appearing after use of class Ic agents or amiodarone for treatment of AF||Catheter ablation∗||I||B||168,169|
|Stop current drug and use another||IIa||C|
|Symptomatic non-CTI-dependent flutter after failed antiarrhythmic drug therapy||Catheter ablation∗||IIa||B||176–178|
The order in which treatment recommendations appear in this table within each class of recommendation does not necessarily reflect a preferred sequence of administration. Please refer to text for details. For pertinent drug dosing information please refer to the ACC/AHA/ESC Guidelines on the Management of Patients With Atrial Fibrillation.
AF indicates atrial fibrillation; AV, atrioventricular; CTI, cavotricuspid isthmus.
↵∗ Catheter ablation of the AV junction and insertion of a pacemaker should be considered if catheter ablative cure is not possible and the patient fails drug therapy.
↵† These drugs should not be taken by patients with significant structural cardiac disease. Use of anticoagulants is identical to that described for patients with AF (http://www.acc.org/clinical/guidelines/atrial_fib/af_index.htm).201
‡ Flecainide, propafenone, procainamide, quinidine, and disopyramide should not be used unless they are combined with an AV-nodal-blocking agent.