Atrial Flutter When Rate Control Has Not Succeeded: What to Do Next
In haemodynamically stable atrial flutter or macro-re-entrant atrial tachycardia, the initial priority is controlling the rapid ventricular rate. When that goal is not achieved, the clinical focus shifts — and a different approach is required.
Clinical scenario
Atrial flutter or macro-re-entrant atrial tachycardia without haemodynamic instability, where ventricular rate control has not been adequately achieved with first-line therapy.
Prior line Goal not reached
Rate control with an i.v. beta-blocker, or i.v. diltiazem or verapamil was the initial approach. The intended target — adequate control of the rapid ventricular rate — was not reached. This protocol represents the next step.
Next step — rhythm conversion
The clinical goal at this stage is conversion to sinus rhythm. Established electrical and pharmacological strategies exist for this purpose, with additional options in patients with certain implanted devices. The specific approach, criteria, and sequencing are set out in the full protocol.
References
DOI: 10.1093/eurheartj/ehz827
- i.v. beta-blockers or non-dihydropyridine calcium channel blockers (verapamil or diltiazem) (i.v.), should be considered for control of rapid ventricular rate.
- i.v. ibutilide or i.v. or oral (in-hospital) dofetilide are recommended for conversion to sinus rhythm.
- Low-energy (≤100 J biphasic) electrical cardioversion is recommended for conversion to sinus rhythm.
- High-rate atrial pacing is recommended for termination of atrial flutter in the presence of an implanted pacemaker or defibrillator.
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