Medical Treatment

Most people with atrial flutter have some form of underlying heart disease. They require medical treatment to reduce their heart rate and to maintain a normal sinus rhythm (normal heart rhythm). The goals of treatment are to control the heart rate, to restore a normal heart rate and sinus rhythm, to prevent future episodes, and to prevent stroke.

Control heart rate: The first treatment goal is to control the ventricular rate.

• If a person experiences serious clinical symptoms, such as chest pain or congestive heart failure related to the ventricular rate, the health care provider in the emergency department will decrease the heart rate rapidly with IV medications or controlled electrical shock (defibrillation) performed under anesthesia. Defibrillation is a technique that uses electrical current to shock the heart back to a normal sinus rhythm. Defibrillation is sometimes called DC cardioversion.
  
  
  • Defibrillation is performed by connecting a device called an external defibrillator to the chest with patches or paddles.
    
    
  • When this technique is performed in a hospital, an anesthetic drug is first given so the person is fully sedated and asleep during the procedure; no pain is associated with the procedure.
    
    
  • Defibrillation works very well; more than 90% of people convert to a normal sinus rhythm. For many, however, this is not a permanent solution-the arrhythmia often returns.
    
    
  • Defibrillation itself increases the risk of stroke and thus, if time allows, requires pretreatment with an anticoagulant medication, usually for three weeks.
  
  
  
• If no serious symptoms have occurred, the person may be given medications by mouth.



• Sometimes, a combination of oral medications is required to control the heart rate.



• In some people, an invasive procedure called radiofrequency catheter ablation may provide long-term successful treatment, and no additional medications may be needed. Radiofrequency catheter ablation is a technique that electronically burns and destroys some abnormal conduction pathways in the atria.



• The abnormal pathways are located, and a catheter is placed at this precise location in the conduction system.



• After proper placement, the catheter delivers radiofrequency energy that interrupts (ablates) a portion of the abnormal electrical conduction pathway. This ablation inactivates the abnormal pathway to provide the normal flow of electrical impulses.



• This technique is safe. When it works, atrial flutter may be permanently cured. Radiofrequency catheter ablation has few complications and, unlike surgery, requires little recovery time.

Restore and maintain a normal rhythm: Some people with newly diagnosed atrial flutter convert to a normal rhythm spontaneously in 24-48 hours; however, the atrial flutter may recur. The goal of treatment is to keep the heart rate normal and to prevent the heart from beating too fast.

• Not everyone with atrial flutter needs anti-arrhythmia medication.
  
  
• The frequency with which the arrhythmia returns and the symptoms it causes partly determine whether anti-arrhythmia medication is indicated.
  
  
• Medical professionals carefully tailor each person's anti-arrhythmia medication to produce the desired clinical effect without making the dose too high.



• Most of these anti-arrhythmia medications cause unwanted side effects, which limit their use.

Prevent future episodes: Prevention usually involves taking daily medication to keep the heart in a normal rhythm.

Prevent stroke: Stroke is a devastating complication of atrial flutter. Stroke occurs when a piece of a blood clot formed in the heart's left atrium breaks off and travels to the brain, where it blocks blood flow.

• Coexisting medical conditions, such as coronary heart disease with atrial flutter, significantly increase the risk of stroke.
  
   
• Most people with atrial flutter, including all people older than 65 years, should take a blood-thinning drug called warfarin (Coumadin) to lower this risk. Warfarin blocks the action of certain factors in the blood that promote clotting. In the short term, most patients are put on IV or subcutaneous (administered by injection under the skin) heparin, a drug that immediately decreases the risk of blood clots. A decision is then made whether oral warfarin is needed on a long-term basis.
  
   
• People at a lower risk of stroke and those who cannot take warfarin may use aspirin. Aspirin is not without its own side effects, including bleeding problems and stomach ulcers.

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