The AHA Guidelines and Scientific Statements Handbook

Chapter 16 Supraventricular Arrhythmias

Table 16.7 Recommendation for acute management of atrial fl utter

Clinical status proposed therapy Recommendation* Classifi cation Level of evidence

Poorly tolerated

• Conversion DC cardioversion I C


• Rate control Beta-blockers IIa C
  Verapamil or diltiazem IIa C
  Digitalis† Ib C
  Amiodarone Ib C
  Stable fl utter


• Conversion Atrial or transesophageal pacing I A
  DC cardioversion I C
  Butilide‡ IIa A
  Flecainide§ Ib A
  Propafenone§ Ib A
  Sotalol Ib C
  Procainamide§ Ib A
  Amiodarone Ib C


• Rate control Diltiazem or verapamil I A
  Beta-blockers I C
  Digitalis† Ib C
  Amiodarone Ib C

The order in which treatment recommendations appear in this table within each class of recommendation does not necessarily refl ect a preferred sequence of admin-
istration. 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 anticoagulanted (NR equals 2 to 3), the arrhythmia is less than 48 hours in duration, or the TEE shows no
atrial clots.

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

atrial fl utter. In a retrospective study [36] of patients
who underwent ablation, 80 patients had no prior
history of atrial fi brillation but 40 (50%) developed
atrial fi brillation after a mean follow-up of 29.6
months. The incidence of fi brillation was progres-
sive with 40% occurring after 2 years. Moreover, the
authors found no difference in age, left atrial size or
presence of structural heart disease between those
that developed atrial fi brillation or who did not.
Similarly, Meissner et al. [37] found a 59.1%
recurrence rate of atrial fi brillation after a mean
follow-up of 3 years. The authors concluded that in

spite of the high rate of progression to atrial fi bril-

lation, there was a signifi cant symptomatic benefi t

and daily work activities and need for hospitaliza-

tion was reduced.

Although the longer term follow-up data suggest

development of a very high incidence of atrial fi bril-

lation, ablation is still indicated as primary therapy

for fl utter, because of better arrhythmia control

compared with drug therapy and because atrial

fl utter may be associated with higher ventricular

rates and more symptoms than attacks of atrial

fi brillation.