Atrial Flutter: Drug Therapy

Therapy goals

  • Restoration of normal sinus rhythm
  • Prevention of apoplexy (stroke).

Therapy recommendations

  • Therapy of atrial flutter with antiarrhythmic drugs (drugs that act against cardiac arrhythmias) is performed only when electrical cardioversion (therapeutic procedure in cardiology to restore sinus rhythm (regular heart rhythm) in an existing arrhythmia) is not available or as an experiment in recurrent (recurring) atrial flutter. Note: Atrial flutter is the only arrhythmia that can be worsened with antiarrhythmic drugs!
  • Anticoagulation; because the thromboembolic risk is not less than in atrial fibrillation (see there), that is, patients with atrial flutter should be treated as in atrial fibrillation with regard to anticoagulation.
    • Decide on therapy for AF and atrial flutter on the basis of the CHA2DS2-VASc score as a clinical measure of risk of future stroke. If the score is 2 (men) and 3 (women) or higher, anticoagulation (class 1A recommendation), preferably with nonvitamin K-dependent oral anticoagulants (NOAKs), is recommended.
    • See “Further guidance” for an opposing opinion.
  • See also under “Further therapy“.

Further notes

  • An observational study of atrial fibrillation versus atrial flutter showed, during a follow-up period of nearly 3 years, that the annual incidence rate of ischemic stroke was 3.08% in the atrial fibrillation group, 1.45% in the atrial flutter group, and 0.97% in the control group, with the same CHA2DS2-VASc score. The mean CHA2DS2-VASc score was 2.2 in the control group, 3.0 in the atrial fibrillation group, and 3.5 in the atrial fibrillation group. The annual incidence rates related to hospitalizations for heart failure were 3.39% (atrial fibrillation), 1.57% (atrial fibrillation), and 0.32% (controls); the rates for all-cause mortality were 17.8% versus 13.9% versus 4.2%. Further analysis of the data explained these differences: a CHA2DS2-VASc score of 2 in the atrial fibrillation group was equivalent to the risk of patients with atrial flutter with a score of 4. That is, patients with atrial flutter did not have a significant increase in risk for apoplexy until a score of 5….