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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Atrial flutter

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Atrial flutter with shock, syncope with severe or ongoing hypotension, myocardial ischaemia, severe pulmonary oedema or immediately after return of spontaneous circulation requires urgent synchronised cardioversion.

Synopsis

Recognise atrial flutter, stabilise a fast ventricular response, prevent thromboembolism and select cardioversion or cavotricuspid-isthmus ablation appropriately.

  • Typical flutter is a macro-re-entrant atrial rhythm, usually circulating around the tricuspid annulus through the cavotricuspid isthmus.
  • An atrial rate near 300/min with 2:1 AV conduction often produces a very regular ventricular rate near 150/min.
  • Flutter waves may be concealed in the QRS or T wave; transient AV block can reveal atrial activity but adenosine does not terminate atrial flutter.
  • Treat instability with a synchronised 70-120 J shock, escalating stepwise if required, with sedation or anaesthesia for a conscious patient where feasible.
  • Stable management addresses ventricular rate, stroke risk, reversible drivers and a rhythm-control plan.
  • Assess thromboembolic risk and cardioversion anticoagulation using the AF framework; restoring sinus rhythm does not automatically remove long-term stroke risk.
  • Cavotricuspid-isthmus ablation is an effective definitive treatment for recurrent or symptomatic typical flutter, but later atrial fibrillation remains possible.

Key red flags

Adverse features

Shock, severe or ongoing hypotensive syncope, myocardial ischaemia, pulmonary oedema or a post-ROSC state mandate emergency treatment.

Investigation priorities

01
12-lead ECGFirst step

Confirm flutter, AV conduction ratio, QRS width and ventricular rate.

Management branches

unstableEmergency flutter

Flutter is accompanied by a life-threatening adverse feature.

  1. Perform ABCDE assessment, attach pads and monitoring, obtain IV access and call for expert resuscitation/anaesthetic help.
  2. For a conscious patient, provide carefully titrated sedation or anaesthesia if this does not delay treatment or worsen haemodynamics.
  3. Deliver a synchronised biphasic shock at 70-120 J; confirm synchronisation is enabled and escalate energy stepwise if unsuccessful.
  4. If up to three shocks fail and instability persists, give RCUK procainamide 10-15 mg/kg IV over 20 minutes (maximum 1 g) or amiodarone 300 mg IV over 10-20 minutes, then repeat synchronised cardioversion.
stableStable ventricular-rate control

No life-threatening adverse feature is present.

  1. Confirm the rhythm and assess LVEF, blood pressure, comorbidity and reversible causes.
  2. Use a beta-blocker for rate control when appropriate; if LVEF is above 40%, verapamil, diltiazem or digoxin are conditional alternatives, while reduced LVEF narrows choices to a beta-blocker or digoxin.
  3. Assess CHA2DS2-VASc stroke risk and bleeding risk and offer anticoagulation when indicated; do not use aspirin as a substitute.

Key medicines

Bisoprolol5 mg by mouth once daily is the cited SmPC starting dose for hypertension or angina; ventricular-rate control in atrial flutter is off-label for this product. Titrate to response, often using a lower initial dose in frail patients or heart failure.Avoid or reduce in symptomatic bradycardia, hypotension, high-grade AV block without pacing or decompensated heart failure; do not stop abruptly.
Apixaban5 mg by mouth twice daily is the licensed dose for eligible NVAF. When used for isolated flutter under the NICE AF/flutter stroke-risk framework, treatment is guideline-directed but outside the cited product's NVAF indication. Reduce to 2.5 mg twice daily when at least two apply: age 80 years or older, weight 60 kg or less, serum creatinine 133 micromol/L or more; for NVAF, also use 2.5 mg twice daily when Cockcroft-Gault creatinine clearance is 15-29 mL/min regardless of the two-of-three rule.Check Cockcroft-Gault renal function, bleeding risk and interactions. Apixaban is not recommended by the cited SmPC when creatinine clearance is below 15 mL/min or during dialysis. Dose reduction is criteria- or severe-renal-impairment-based, not a general response to age alone.
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Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • Resuscitation Council UK: Adult advanced life support 2025Instability criteria, synchronised shock energy and failed-cardioversion drugs.
  • Resuscitation Council UK: Adult tachyarrhythmia algorithm, March 2026Current peri-arrest algorithm and ventricular-rate choices by LVEF.
  • NICE NG196: Atrial fibrillation – recommendationsStroke-risk assessment, anticoagulation and cardioversion framework used for flutter.
  • ESC: 2019 supraventricular tachycardia guidelineFlutter diagnosis and ablation strategy.
  • eMC: Bisoprolol fumarate 5 mg SmPCLicensed oral dose and contraindications.
  • eMC: Eliquis 5 mg SmPCNVAF dose and exact reduction criteria.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
Arrange cardiology/electrophysiology review for rhythm control, especially when symptoms persist or rate control is difficult.