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I B-NR 4.  Ongoing management with antithrombotic therapy is recommended in patients with atrial flutter to align with recommended antithrombotic therapy for patients with AF.365

See Online Data Supplements 16 and 17. The risk of stroke associated with AF is well established, and several RCTs have demonstrated the efficacy of anticoagulation for stroke prevention in patients with additional risk factors.366 Anticoagulation has also been shown to prevent stroke when administered during the weeks immediately before and after cardioversion.367 Whether atrial flutter carries a risk of stroke similar to that in patients with AF has been debated in the past but is now supported by limited evidence from mechanistic, observational, and prospective studies that include patients primarily with atrial flutter.365–369 Several reports have suggested that the risk of stroke in patients with atrial flutter is mitigated by anticoagulation. Meta-analysis of 13 studies of patients undergoing cardioversion of atrial flutter reported short-term stroke risks ranging from 0% to 7%, and the thromboembolism rate in patients with sustained flutter in 4 studies averaged 3% annually.365 Other studies have reported similar risk and effectiveness of anticoagulation.369 Therefore, on the basis of available data, recommendations for antithrombotic therapy for patients with atrial flutter are similar to those for patients with AF.10

IIa B-R 1.  The following drugs can be useful to maintain sinus rhythm in patients with symptomatic, recurrent atrial flutter, with the drug choice depending on underlying heart disease and comorbidities: a.  Amiodarone376

b.  Dofetilide346,377 c.  Sotalol378

See Online Data Supplements 16 and 17. In patients in whom ablation is not being considered because of contraindications (such as underlying medical illness) or because of patient preference, a variety of antiarrhythmic drugs are available. These drugs act by suppressing triggers and altering atrial tissue refractoriness. Individual properties of each drug need to be considered for proper use. Much of the data pertaining to use of amiodarone in management of atrial arrhythmias has been derived from use in patients with AF.10 Few data are available for patients with atrial flutter. Amiodarone has significant toxicities, so it is used only when other treatments are contraindicated or ineffective. Nevertheless, administration is reasonable, particularly in patients with heart failure or significant underlying heart disease.376

Dofetilide may be more effective than many other drugs but must be started in an inpatient setting.346,377 The dose is adjusted on the basis of renal function, with close monitoring of the Q-T interval and subsequent monitoring for altered renal function. Sotalol, a class III antiarrhythmic, is generally well tolerated but is associated with typical beta blocker side effects, such as fatigue and bradycardia.378 The major potential cardiac toxicity for both drugs is torsades de pointes.

IIa B-NR 2.  Catheter ablation is reasonable in patients with CTI-dependent atrial flutter that occurs as the result of flecainide, propafenone, or amiodarone used for treatment of AF.317,379–381 See Online Data Supplements 16 and 17. Some patients with AF treated with propafenone, flecainide, or amiodarone will develop atrial flutter. In this circumstance, if flutter becomes the dominant arrhythmia, ablation of the CTI and continued use of the antiarrhythmic drug can decrease the incidence of atrial flutter and facilitate the pharmacological management of AF.379,380 IIa C-LD 3.  Catheter ablation of the CTI is reasonable in patients undergoing catheter ablation of AF who also have a history of documented clinical or induced CTI-dependent atrial flutter.381,382

See Online Data Supplements 16 and 17. The indications for catheter ablation of AF are discussed in the 2014 AF guideline.10 When AF and atrial flutter coexist, 1 randomized study demonstrated that at 1-year follow-up, greater success in terms of arrhythmia suppression and quality-of-life score resulted from AF ablation (with or without atrial flutter ablation) than from atrial flutter ablation alone.381 It may be that AF ablation alone is sufficient to control both arrhythmias, although CTI ablation reduced the early postablation arrhythmia recurrence rate.382

IIa C-LD 4.  Catheter ablation is reasonable in patients with recurrent symptomatic non–CTI-dependent flutter as primary therapy, before therapeutic trials of antiarrhythmic drugs, after carefully weighing potential risks and benefits of treatment options.135

See Online Data Supplements 16 and 17. No prospective RCTs have compared the efficacy or safety of antiarrhythmic drugs with that of catheter ablation for non–CTI-dependent atrial flutter. Observational data, however, support the relative effectiveness and safety of catheter ablation in experienced centers.135,327 Many of the atrial flutters that are observed during the first 3 months after ablation or cardiac surgery will not persist beyond the periprocedural period, so attempts at ablation can be deferred unless attempts at pharmacological therapy or cardioversion are unsuccessful.135 IIb B-R 1.  Flecainide or propafenone may be considered to maintain sinus rhythm in patients without structural heart disease or ischemic heart disease who have symptomatic recurrent atrial flutter.383–385

See Online Data Supplements 16 and 17. Data to support the recommendation for flecainide and propafenone for maintenance of sinus rhythm in patients with atrial flutter is derived from trials that pooled patients with AF and atrial flutter, with the vast majority of the patients having AF. It is therefore possible that these agents are not as effective for treating isolated atrial flutter as they are for AF.386 Flecainide and propafenone may result in slowing of the atrial flutter cycle length, which may lead to a rapid 1:1 ventricular response.387 Because of this, caution is advised with flecainide and propafenone in patients with atrial flutter at risk of 1:1 conduction. The risk may be reduced by coadministration of medications that slow AV nodal conduction, such as beta blockers, verapamil, or diltiazem. IIb C-LD 2.  Catheter ablation may be reasonable for asymptomatic patients with recurrent atrial flutter.102,121,372 See Online Data Supplements 16 and 17. Catheter ablation of atrial flutter is highly effective, with single-procedure success rates >90%102 and an excellent safety profile.102,121 In patients with recurrent atrial flutter, long-term maintenance of sinus rhythm is more likely with ablation than with pharmacological therapy.372 Also, ablation may avoid potential development of tachycardia-mediated cardiomyopathy.

Recommendations for Ongoing Management of Atrial Flutter (Continued) COR LOE Recommendations

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