Restoration of sinus rhythm in atrial flutter
- Jordan M Prutkin, MD, MHS, FHRS
Jordan M Prutkin, MD, MHS, FHRS
- Associate Professor of Medicine, Division of Cardiology, Electrophysiology Section
- University of Washington
Atrial flutter is a supraventricular arrhythmia that can cause unacceptable symptoms and that can promote atrial thrombus formation with the potential for systemic embolization. Restoration of sinus rhythm improves symptoms and decreases the risk of embolization if recurrence does not occur. (See "Overview of atrial flutter", section on 'Clinical manifestations' and "Embolic risk and the role of anticoagulation in atrial flutter", section on 'Embolic risk'.)
Issues related to the indications and therapeutic options for the restoration of sinus rhythm in atrial flutter will be reviewed here. Causes of atrial flutter, rate control therapy, the maintenance of sinus rhythm after cardioversion, and the role of anticoagulation in atrial flutter are discussed separately. (See "Control of ventricular rate in atrial flutter" and "Atrial flutter: Maintenance of sinus rhythm" and "Embolic risk and the role of anticoagulation in atrial flutter".)
Atrial flutter is a relatively common supraventricular arrhythmia that is characterized by rapid, regular atrial depolarizations at a characteristic rate of approximately 300 beats/min. (See "ECG tutorial: Atrial and atrioventricular nodal (supraventricular) arrhythmias", section on 'Atrial fibrillation and atrial flutter' and "Overview of atrial flutter".)
In the absence of rate slowing drugs or atrioventricular (AV) nodal disease, every other beat passes through the AV node and the ventricular rate is usually around 150 beats per minute. Consequent to tachycardia, the patient may present with symptoms of palpitations, chest pain, dyspnea, fatigue, dizziness, and rarely hemodynamic shock, similar to patients with atrial fibrillation (AF) with a rapid ventricular response. (See "Hemodynamic consequences of atrial fibrillation and cardioversion to sinus rhythm", section on 'Adverse hemodynamics in AF'.)
In addition to improving symptoms, the restoration of sinus rhythm prevents the potential for the development of tachycardia-mediated cardiomyopathy or systemic embolization. (See "Arrhythmia-induced cardiomyopathy", section on 'Atrial fibrillation and atrial flutter' and "Embolic risk and the role of anticoagulation in atrial flutter", section on 'Embolic risk'.)
- Gallagher MM, Guo XH, Poloniecki JD, et al. Initial energy setting, outcome and efficiency in direct current cardioversion of atrial fibrillation and flutter. J Am Coll Cardiol 2001; 38:1498.
- Van Gelder IC, Crijns HJ, Van Gilst WH, et al. Prediction of uneventful cardioversion and maintenance of sinus rhythm from direct-current electrical cardioversion of chronic atrial fibrillation and flutter. Am J Cardiol 1991; 68:41.
- Naccarelli GV, Dell'Orfano JT, Wolbrette DL, et al. Cost-effective management of acute atrial fibrillation: role of rate control, spontaneous conversion, medical and direct current cardioversion, transesophageal echocardiography, and antiembolic therapy. Am J Cardiol 2000; 85:36D.
- Stambler BS, Wood MA, Ellenbogen KA, et al. Efficacy and safety of repeated intravenous doses of ibutilide for rapid conversion of atrial flutter or fibrillation. Ibutilide Repeat Dose Study Investigators. Circulation 1996; 94:1613.
- Ellenbogen KA, Stambler BS, Wood MA, et al. Efficacy of intravenous ibutilide for rapid termination of atrial fibrillation and atrial flutter: a dose-response study. J Am Coll Cardiol 1996; 28:130.
- Abi-Mansour P, Carberry PA, McCowan RJ, et al. Conversion efficacy and safety of repeated doses of ibutilide in patients with atrial flutter and atrial fibrillation. Study Investigators. Am Heart J 1998; 136:632.
- Stambler BS, Wood MA, Ellenbogen KA. Antiarrhythmic actions of intravenous ibutilide compared with procainamide during human atrial flutter and fibrillation: electrophysiological determinants of enhanced conversion efficacy. Circulation 1997; 96:4298.
- Volgman AS, Carberry PA, Stambler B, et al. Conversion efficacy and safety of intravenous ibutilide compared with intravenous procainamide in patients with atrial flutter or fibrillation. J Am Coll Cardiol 1998; 31:1414.
- Vos MA, Golitsyn SR, Stangl K, et al. Superiority of ibutilide (a new class III agent) over DL-sotalol in converting atrial flutter and atrial fibrillation. The Ibutilide/Sotalol Comparator Study Group. Heart 1998; 79:568.
- Kafkas NV, Patsilinakos SP, Mertzanos GA, et al. Conversion efficacy of intravenous ibutilide compared with intravenous amiodarone in patients with recent-onset atrial fibrillation and atrial flutter. Int J Cardiol 2007; 118:321.
- Glatter K, Yang Y, Chatterjee K, et al. Chemical cardioversion of atrial fibrillation or flutter with ibutilide in patients receiving amiodarone therapy. Circulation 2001; 103:253.
- Patsilinakos S, Christou A, Kafkas N, et al. Effect of high doses of magnesium on converting ibutilide to a safe and more effective agent. Am J Cardiol 2010; 106:673.
- Tercius AJ, Kluger J, Coleman CI, White CM. Intravenous magnesium sulfate enhances the ability of intravenous ibutilide to successfully convert atrial fibrillation or flutter. Pacing Clin Electrophysiol 2007; 30:1331.
- Singh S, Zoble RG, Yellen L, et al. Efficacy and safety of oral dofetilide in converting to and maintaining sinus rhythm in patients with chronic atrial fibrillation or atrial flutter: the symptomatic atrial fibrillation investigative research on dofetilide (SAFIRE-D) study. Circulation 2000; 102:2385.
- Mounsey JP, DiMarco JP. Cardiovascular drugs. Dofetilide. Circulation 2000; 102:2665.
- Abraham JM, Saliba WI, Vekstein C, et al. Safety of oral dofetilide for rhythm control of atrial fibrillation and atrial flutter. Circ Arrhythm Electrophysiol 2015; 8:772.
- Falk RH, Pollak A, Singh SN, Friedrich T. Intravenous dofetilide, a class III antiarrhythmic agent, for the termination of sustained atrial fibrillation or flutter. Intravenous Dofetilide Investigators. J Am Coll Cardiol 1997; 29:385.
- Nørgaard BL, Wachtell K, Christensen PD, et al. Efficacy and safety of intravenously administered dofetilide in acute termination of atrial fibrillation and flutter: a multicenter, randomized, double-blind, placebo-controlled trial. Danish Dofetilide in Atrial Fibrillation and Flutter Study Group. Am Heart J 1999; 137:1062.
- Bianconi L, Castro A, Dinelli M, et al. Comparison of intravenously administered dofetilide versus amiodarone in the acute termination of atrial fibrillation and flutter. A multicentre, randomized, double-blind, placebo-controlled study. Eur Heart J 2000; 21:1265.
- Schamroth L, Krikler DM, Garrett C. Immediate effects of intravenous verapamil in cardiac arrhythmias. Br Med J 1972; 1:660.
- Hagemeijer F. Verapamil in the management of supraventricular tachyarrhythmias occurring after a recent myocardial infarction. Circulation 1978; 57:751.
- Wolfson S, Herman MV, Sullivan JM, Gorlin R. Conversion of atrial fibrillation and flutter by propranolol. Br Heart J 1967; 29:305.
- Pratt CM, Roy D, Torp-Pedersen C, et al. Usefulness of vernakalant hydrochloride injection for rapid conversion of atrial fibrillation. Am J Cardiol 2010; 106:1277.
- Saoudi N, Atallah G, Kirkorian G, Touboul P. Catheter ablation of the atrial myocardium in human type I atrial flutter. Circulation 1990; 81:762.
- Da Costa A, Thévenin J, Roche F, et al. Results from the Loire-Ardèche-Drôme-Isère-Puy-de-Dôme (LADIP) trial on atrial flutter, a multicentric prospective randomized study comparing amiodarone and radiofrequency ablation after the first episode of symptomatic atrial flutter. Circulation 2006; 114:1676.
- Das G, Anand KM, Ankineedu K, et al. Atrial pacing for cardioversion of atrial flutter in digitalized patients. Am J Cardiol 1978; 41:308.
- Waldo AL, MacLean WA, Karp RB, et al. Entrainment and interruption of atrial flutter with atrial pacing: studies in man following open heart surgery. Circulation 1977; 56:737.
- Waldo AL, Carlson MD, Biblo LA, Henthorn RW. The role of transient entrainment in atrial flutter. In: Atrial Arrhythmias: Current Concepts and Management, Tourboul P, Waldo AL (Eds), Mosby Year Book, St Louis 1990. p.210.
- Greenberg ML, Kelly TA, Lerman BB, DiMarco JP. Atrial pacing for conversion of atrial flutter. Am J Cardiol 1986; 58:95.
- Cheng J, Scheinman MM. Acceleration of typical atrial flutter due to double-wave reentry induced by programmed electrical stimulation. Circulation 1998; 97:1589.
- Peters RW, Shorofsky SR, Pelini M, et al. Overdrive atrial pacing for conversion of atrial flutter: comparison of postoperative with nonpostoperative patients. Am Heart J 1999; 137:100.
- Orlando J, Cassidy J, Aronow WS. High reversion of atrial flutter to sinus rhythm after atrial pacing in patients with pulmonary disease. Chest 1977; 71:580.
- Resnekov L. Cardiac arrhythmias. 6. Present status of electroversion in the management of cardiac dysrhythmias. Circulation 1973; 47:1356.
- Mann DL, Maisel AS, Atwood JE, et al. Absence of cardioversion-induced ventricular arrhythmias in patients with therapeutic digoxin levels. J Am Coll Cardiol 1985; 5:882.
- Cheng J, Glatter K, Yang Y, et al. Electrophysiological response of the right atrium to ibutilide during typical atrial flutter. Circulation 2002; 106:814.
- Olshansky B, Okumura K, Hess PG, et al. Use of procainamide with rapid atrial pacing for successful conversion of atrial flutter to sinus rhythm. J Am Coll Cardiol 1988; 11:359.
- Stambler BS, Wood MA, Ellenbogen KA. Comparative efficacy of intravenous ibutilide versus procainamide for enhancing termination of atrial flutter by atrial overdrive pacing. Am J Cardiol 1996; 77:960.
- Crawford W, Plumb VJ, Epstein AE, Kay GN. Prospective evaluation of transesophageal pacing for the interruption of atrial flutter. Am J Med 1989; 86:663.
- Doni F, Della Bella P, Kheir A, et al. Atrial flutter termination by overdrive transesophageal pacing and the facilitating effect of oral propafenone. Am J Cardiol 1995; 76:1243.
- D'Este D, Bertaglia E, Mantovan R, et al. Efficacy of intravenous propafenone in termination of atrial flutter by overdrive transesophageal pacing previously ineffective. Am J Cardiol 1997; 79:500.
- Barold SS, Wyndham CR, Kappenberger LL, et al. Implanted atrial pacemakers for paroxysmal atrial flutter. Long-term efficacy. Ann Intern Med 1987; 107:144.
- Israel CW, Ehrlich JR, Grönefeld G, et al. Prevalence, characteristics and clinical implications of regular atrial tachyarrhythmias in patients with atrial fibrillation: insights from a study using a new implantable device. J Am Coll Cardiol 2001; 38:355.
- Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. Circulation 2008; 117:e350.
- Tracy CM, Epstein AE, Darbar D, et al. 2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Heart Rhythm 2012; 9:1737.
- You JJ, Singer DE, Howard PA, et al. Antithrombotic therapy for atrial fibrillation: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e531S.
- January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:2071.
- January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation 2014; 130:e199.
- METHOD OF CARDIOVERSION
- Electrical Cardioversion
- - Pharmacologic enhancement of direct current cardioversion
- Pharmacologic cardioversion
- Radiofrequency catheter ablation
- Atrial pacing
- MAINTENANCE OF SINUS RHYTHM
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS