Guideline sources The following summarized guidelines for the evaluation and management of atrial flutter are prepared by our editorial team based on guidelines from the European Society of Cardiology (ESC/EACTS/EHRA 2021), the European Society of Cardiology (ESC 2020; 2018), the Canadian Cardiovascular Society (CCS/CHRS 2020), the American Heart Association (AHA/HRS/ACC 2019; 2016; 2014), the Canadian Cardiovascular Society (CCS 2018; 2014), and the Latin American Heart Rhythm Society (SOLAECE/ECAS/APHRS/EHRA/HRS 2017). 1 2 3 4 5 6 7 8 9 10 Guidelines 1. Classification and risk stratification Stroke risk assessment: stratify all patients with atrial flutter, whether paroxysmal or persistent, using a predictive index for stroke risk. A 2. Medical management Acute rhythm control: https://web.pathway.md/diseases/recCej7N2vg1HZE82 1/6 6/23/23, 3:15 AM Atrial flutter Pathway As per ESC 2020 guidelines: Administer IV ibutilide or IV or oral (in-hospital) dofetilide for pharmacological cardioversion in hemodynamically stable patients with macroreentrant atrial arrhythmia. B Do not use propafenone or flecainide for pharmacological cardioversion in hemodynamically stable patients with macroreentrant atrial arrhythmia. D As per AHA 2016 guidelines, administer oral dofetilide or IV ibutilide for acute pharmacological cardioversion in stable patients with atrial flutter. A Show 2 more As per ACC 2014 guidelines: Administer flecainide, dofetilide, propafenone, or IV ibutilide for cardioversion in patients with atrial flutter, in the absence of contraindications. A Do not initiate dofetilide out of hospital. D Acute rate control: As per ESC 2020 guidelines: Consider administering IV -blockers or nondihydropyridine CCBs (verapamil or diltiazem) for control of rapid ventricular rate in hemodynamically stable patients with macroreentrant atrial arrhythmia. C Consider administering IV amiodarone if the above agents are not available or desirable. C As per AHA 2016 guidelines: Administer IV or oral -blockers, diltiazem, or verapamil for acute rate control in hemodynamically stable patients with atrial flutter. B Consider administering IV amiodarone for acute rate control (in the absence of pre-excitation) in patients with atrial flutter and systolic HF, if -blockers are contraindicated or ineffective. C Chronic rhythm control: As per ESC 2020 guidelines: Consider initiating -blockers or nondihydropyridine CCBs (verapamil or diltiazem, in the absence of HFrEF) if ablation is not desirable or feasible. Consider initiating -blockers for the management of patients with recurrent atrial flutter if ablation is not possible or successful. C Consider initiating amiodarone to maintain sinus rhythm if the above agents and/or catheter ablation fail. C As per AHA 2016 guidelines, consider using the following medications for maintaining sinus rhythm in symptomatic patients with recurrent atrial flutter, with the medication choice depending on underlying heart disease and comorbidities: amiodarone dofetilide sotalol. C Show 2 more Chronic rate control: initiate -blockers, diltiazem, or verapamil to control the ventricular rate in patients with hemodynamically tolerated atrial flutter. B https://web.pathway.md/diseases/recCej7N2vg1HZE82 2/6 6/23/23, 3:15 AM Atrial flutter Pathway Antithrombotic therapy: As per ESC 2020 guidelines: Consider initiating anticoagulation in patients with atrial flutter without AF, but the threshold for initiation has not been established. C Initiate anticoagulation in patients with atrial flutter and concomitant AF as for patients with AF. B As per AHA 2019 guidelines, initiate anticoagulant therapy in patients with atrial flutter according to the same risk profile used for AF. B As per CCS 2018 guidelines, avoid initiating antithrombotic therapy for stroke prevention in < 65 years old patients with atrial flutter with no CHADS2 risk factors. D As per AHA 2016 guidelines, initiate acute antithrombotic therapy in patients with atrial flutter to align with recommended antithrombotic therapy for patients with AF. B Show 2 more 3. Therapeutic procedures Electrical cardioversion: As per ESC 2020 guidelines: Perform synchronized direct cuttent cardioversion in hemodynamically unstable patients with macroreentrant atrial arrhythmia. B Perform low-energy (100 J biphasic) electrical cardioversion in hemodynamically stable patients with macroreentrant atrial arrhythmia. B As per CCS 2018 guidelines, consider performing immediate electrical cardioversion if the recent-onset atrial flutter is causing hemodynamic instability with hypotension, acute coronary syndrome, or pulmonary edema. B As per AHA 2016 guidelines, perform synchronized cardioversion for acute management of hemodynamically unstable patients with atrial flutter not responding to pharmacological therapies. B Show 2 more As per ACC 2014 guidelines, perform cardioversion to restore sinus rhythm in patients with atrial flutter. Consider repeating attempts if unsuccessful. B Show 2 more Atrial pacing: As per ESC 2020 guidelines: Perform high-rate atrial pacing for termination of atrial flutter in the presence of an implanted pacemaker or defibrillator in hemodynamically stable patients. B Consider performing invasive or noninvasive high-rate atrial pacing for termination of atrial flutter in hemodynamically stable patients. C As per AHA 2016 guidelines: https://web.pathway.md/diseases/recCej7N2vg1HZE82 3/6 6/23/23, 3:15 AM Atrial flutter Pathway Perform rapid atrial pacing for acute conversion of atrial flutter in patients having pacing wires in place as part of a permanent pacemaker or implantable cardioverter-defibrillator or for temporary atrial pacing after cardiac surgery. B Consider performing atrial pacing to decrease recurrences of atrial flutter in adult patients with congenital heart disease and SND. C Catheter ablation: As per CCS 2020 guidelines, perform catheter ablation of typical RA flutter as a reasonable alternative to pharmacologic rhythm or rate control therapy. B As per HRS 2017 guidelines: Perform a linear ablation of the cavotricuspid isthmus in patients with a history of typical atrial flutter, or if typical atrial flutter is induced at the time of AF ablation. B Insufficient evidence to recommend linear ablation in the absence of macroreentrant atrial flutter. I As per AHA 2016 guidelines, perform catheter ablation of the cavotricuspid isthmus in patients with atrial flutter that is either symptomatic or refractory to pharmacological rate control. B Show 5 more Catheter ablation (ECS): consider performing catheter ablation after the first episode of symptomatic typical atrial flutter. C Show 3 more AV nodal ablation: consider performing atrioventricular nodal ablation with subsequent pacing ("ablate and pace"), either biventricular or His-bundle pacing, if catheter ablation and pharmacological rhythm control fail and the patient has symptomatic persistent macroreentrant atrial arrhythmia with fast ventricular rates. C 4. Perioperative care Pericardioversion thromboprophylaxis: As per ESC 2021 guidelines, administer effective anticoagulation for a minimum of 3 weeks before cardioversion of atrial flutter. B Show 3 more As per AHA 2019 guidelines, consider administering heparin, a factor Xa inhibitor, or a direct thrombin inhibitor in patients with atrial flutter of < 48 hours duration with a CHA2DS2-VASc score of 0 in males and 1 in females before cardioversion, without the need for post- cardioversion oral anticoagulation. C Show 4 more As per CCS 2018 guidelines, initiate therapeutic anticoagulation, in addition to appropriate rate control, for 3 weeks before cardioversion in most hemodynamically stable patients with atrial flutter planned to undergo electrical or pharmacological cardioversion. B Show 4 more https://web.pathway.md/diseases/recCej7N2vg1HZE82 4/6 6/23/23, 3:15 AM Atrial flutter Pathway 5. Surgical interventions Surgical ablation: consider performing surgical ablation of atrial flutter in adult patients with congenital heart disease undergoing planned surgical repair. C 6. Specific circumstances Patients with congenital heart disease: As per ESC 2021 guidelines, consider initiating OACs in all adult patients with intracardiac repair, cyanosis, Fontan palliation, or systemic right ventricle and a history of atrial flutter. C As per ACC 2016 guidelines, initiate acute antithrombotic therapy in patients with atrial flutter and adult congenital heart disease patients to align with recommended antithrombotic therapy for patients with AF. B Pregnant patients: As per ESC 2020 guidelines, consider administering IV ibutilide for termination of atrial flutter in pregnant patients. C As per ESC 2018 guidelines, consider administering ibutilide or flecainide for termination of atrial flutter in stable pregnant patients with structurally normal hearts. C 7. Follow-up and surveillance Follow-up: monitor patients after atrial flutter ablation for the occurrence of AF with opportunistic screening conducted at the time of medical encounters. B References 1. 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