TABLE 7

Recommendations for Acute Management of Atrial Flutter

Clinical Status/Proposed TherapyRecommendationClassificationLevel of EvidenceReferences
Poorly tolerated
 •ConversionDC cardioversionIC
 •Rate controlBeta blockersIIaC
Verapamil or diltiazemIIaC
DigitalisIIbC
AmiodaroneIIbC
Stable flutter
 •ConversionAtrial or transesophageal pacingIA152,153,186–188
DC cardioversionIC189
IbutilideIIaA192,193
Flecainide§IIbA190,191
Propafenone§IIbA190,191
SotalolIIbC151,194
Procainamide§IIbA150
AmiodaroneIIbC23,195
 •Rate controlDiltiazem or verapamilIA19,196–198
Beta blockersIC197
DigitalisIIbC196
AmiodaroneIIbC195

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.

Cardioversion should be considered only if the patient is anticoagulated (INR equals 2 to 3), the arrhythmia is less than 48 hours in duration, or the TEE shows no atrial clots.

AV indicates atrioventricular; DC, direct current; INR, international normalized ratio; LV, left ventricular; TEE, transesophageal echocardiography.

  • All drugs are administered intravenously.

  • Digitalis may be especially useful for rate control in patients with heart failure.

  • Ibutilide should not be taken by patients with reduced LV function.

  • § Flecainide, propafenone, and procainamide should not be used unless they are combined with an AV-nodal-blocking agent.