Supraventricular tachycardia AHA recommendations for Management of Atrial Flutter

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2015 ACC/AHA Guideline Recommendations

Acute Treatment of SVT of Unknown Mechanism
Ongoing Management of SVT of Unknown Mechanism
Ongoing Management of IST
Acute Treatment of Suspected Focal Atrial Tachycardia
Acute Treatment of Multifocal Atria Tachycardia
Ongoing Management of Multifocal Atrial Tachycardia
Acute Treatment of AVNRT
Ongoing Management of AVNRT
Acute Treatment of Orthodromic AVRT
Ongoing Management of Orthodromic AVRT
Asymptomatic Patients With Pre-Excitation
Management of Symptomatic Patients With Manifest Accessory Pathways
Acute Treatment of Atrial Flutter
Ongoing Management of Atrial Flutter
Acute Treatment of Junctional Tachycardia
Ongoing Management of Junctional Tachycardia
Acute Treatment of SVT in ACHD Patients
Ongoing Management of SVT in ACHD Patients
Acute Treatment of SVT in Pregnant Patients
Acute Treatment and Ongoing Management of SVT in Older Population

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]

Overview

Oral dofetilide or intravenous ibutilide is useful for acute pharmacological cardioversion in patients with atrial flutter. Intravenous or oral beta blockers, diltiazem, or verapamil are useful for acute rate control in patients with atrial flutter who are hemodynamically stable. Elective synchronized cardioversion is indicated in stable patients with well-tolerated atrial flutter when a rhythm-control strategy is pursued. Rapid atrial pacing is useful for acute conversion of atrial flutter in patients who have pacing wires in place as part of a permanent pacemaker or implantable cardioverter-defibrillator or for temporary atrial pacing after cardiac surgery. Acute antithrombotic therapy is recommended in patients with atrial flutter to align with recommended antithrombotic therapy for patients with AF. Catheter ablation of the CTI (cavotricuspid isthmus) is useful in patients with atrial flutter that is either symptomatic or refractory to pharmacological rate control. Beta blockers, diltiazem, or verapamil are useful to control the ventricular rate in patients with hemodynamically tolerated atrial flutter. Amiodarone, Dofetilide, and [[Sotalol] 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.[1]

Management of Atrial Flutter

2015 AHA recommendations for the acute and ongoing management of atrial flutter are described below:[1]

Acute treatment of Atrial Flutter

Class I
"1. Oral dofetilide or intravenous ibutilide is useful for acute pharmacological cardioversion in patients with atrial flutter "(Level of Evidence: A ) "
"2. Intravenous or oral beta blockers, diltiazem, or verapamil are useful for acute rate control in patients with atrial flutter who are hemodynamically stable"(Level of Evidence: B-R) "
"3. Elective synchronized cardioversion is indicated in stable patients with well-tolerated atrial flutter when a rhythm-control strategy is pursued "(Level of Evidence:B-NR ) "
"4. Synchronized cardioversion is recommended for acute treatment of patients with atrial flutter who are hemodynamically unstable and do not respond to pharmacological therapies "(Level of Evidence: B-NR ) "
"5. Rapid atrial pacing is useful for acute conversion of atrial flutter in patients who have pacing wires in place as part of a permanent pacemaker or implantable cardioverter-defibrillator or for temporary atrial pacing after cardiac surgery"(Level of Evidence: C-LD ) "
"6. Acute antithrombotic therapy is recommended in patients with atrial flutter to align with recommended antithrombotic therapy for patients with AF "(Level of Evidence:B-NR ) "
Class IIa
"1. Intravenous amiodarone can be useful for acute control of the ventricular rate (in the absence of pre-excitation in patients with atrial flutter and systolic heart failure, when beta blockers are contraindicated or ineffective"(Level of Evidence:B-R ) "

Management of ongoing Atrial Flutter

Class I
"1. Catheter ablation of the CTI (cavotricuspid isthmus) is useful in patients with atrial flutter that is either symptomatic or refractory to pharmacological rate control"(Level of Evidence:B-R ) "
"2. Beta blockers, diltiazem, or verapamil are useful to control the ventricular rate in patients with hemodynamically tolerated atrial flutter"(Level of Evidence:C-LD ) "
"3. Catheter ablation is useful in patients with recurrent symptomatic non–CTI-dependent flutter after failure of at least 1 antiarrhythmic agent"(Level of Evidence:C-LD ) "
"4. Ongoing management with antithrombotic therapy is recommended in patients with atrial flutter to align with recommended antithrombotic therapy for patients with AF"(Level of Evidence:B-NR ) "
Class IIa
"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. Amiodarone b. Dofetilide c. Sotalol"(Level of Evidence:B-R ) "

"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"(Level of Evidence:B-NR ) "
"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 "(Level of Evidence: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"(Level of Evidence:C-LD ) "

References

  1. 1.0 1.1 Page RL, Joglar JA, Caldwell MA, Calkins H, Conti JB, Deal BJ; et al. (2016). "2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society". J Am Coll Cardiol. 67 (13): e27–e115. doi:10.1016/j.jacc.2015.08.856. PMID 26409259.