Internal Medicine

P1: SBT

0521779407-05 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:49

Atrial Flutter 193

■In stable patients: beta blockers or calcium channel blockers (ver-

apamil, diltiazem), either IV or PO, to slow ventricular response.

Digoxin usually ineffective.

■Cardioversion to NSR: use DC shock, IV ibutilide (1–2 h), IV or PO

procainamide, sotalol, flecainide, propafanone or amiodarone

Chronic

■Exclude atrial clot by transesophageal echo; or warfarin Rx with INR

of 2–3 for 4 weeks before cardioversion (see AF)

■Chronic anticoagulation with warfarin (see guidelines for AF)

■Radiofrequency ablation: best Rx for chronic atrial flutter. In CTI-

dependent atrial flutter, 90–100% cure with RF ablation in the tri-

cuspid annulus-inferior vena cava isthmus.

■Maintenance of NSR:

■Propafenone (absence of structural heart disease), sotalol (LVEF >

30%) or amiodarone.

■Control of ventricular response: beta blockers > calcium channel

blockers

Side Effects & Contraindications

■Potentially life-threatening proarrhythmia possible with antiar-

rhythmic therapy. Rapid ventricular response from 1:1 AV conduc-

tion with propafenone or flecainide.

follow-up

During Treatment

■Beta blockers or calcium channel blockers during acute Rx: monitor

BP and HR

■Chronic antiarrhythmic Rx: ECG at regular intervals to monitor

AV conduction, QRS and QT duration and ventricular arrhythmias.

Holter to identify asymptomatic atrial flutter or heart block.

■Ibutilide, sotalol and propafenone require ECG telemetry monitor-

ing at start of Rx.

■Amiodarone: Biannual thyroid function tests and chest x-ray

complications and prognosis

■Risk of thromboembolism uncertain. No consensus on use of war-

farin or aspirin. Same anticoagulation protocol as patients with atrial

fibrillation recommended.

■Cardiomyopathy in atrial flutter with chronic rapid ventricular

response