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.
Key red flags
Shock, severe or ongoing hypotensive syncope, myocardial ischaemia, pulmonary oedema or a post-ROSC state mandate emergency treatment.
Investigation priorities
Confirm flutter, AV conduction ratio, QRS width and ventricular rate.
Management branches
Flutter is accompanied by a life-threatening adverse feature.
- Perform ABCDE assessment, attach pads and monitoring, obtain IV access and call for expert resuscitation/anaesthetic help.
- For a conscious patient, provide carefully titrated sedation or anaesthesia if this does not delay treatment or worsen haemodynamics.
No life-threatening adverse feature is present.
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.
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.