TABLE 8

Recommendations for Long-Term Management of Atrial Flutter

Clinical Status/Proposed TherapyRecommendationClassificationLevel of EvidenceReferences
First episode and well-tolerated atrial flutterCardioversion aloneIB189
Catheter ablationIIaB164
Recurrent and well-tolerated atrial flutterCatheter ablationIB162,163,199
DofetilideIIaC154,155
Amiodarone, sotalol, flecainide,†‡quinidine,†‡propafenone,†‡procainamide,†‡disopyramide†‡IIbC23,156,200
Poorly tolerated atrial flutterCatheter ablationIB162,163,199
Atrial flutter appearing after use of class Ic agents or amiodarone for treatment of AFCatheter ablationIB168,169
Stop current drug and use anotherIIaC
Symptomatic non-CTI-dependent flutter after failed antiarrhythmic drug therapyCatheter ablationIIaB176–178

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.