Controlling the heart rate and rhythm with medications

It is important to keep the heart rate under control when atrial flutter is diagnosed. This is partly because a high heart rate is often responsible for symptoms. In addition, if the heart rate is poorly controlled for longer periods of time, this can affect the heart’s pumping function.

The first-line therapy for heart rate control is usually a beta-blocker, such as bisoprolol, metoprolol, carvedilol or atenolol. The aim is to get the heart rate between 60 and 100 beats per minute most of the time, especially when at rest. If beta-blockers cause side effects (such as fatigue, lethargy, problems with sleeping or sex drive) then a reasonable alternative is a calcium channel blocker such as verapamil or diltiazem.

Sometimes other medications such as digoxin or amiodarone are recommended in addition to either a beta-blocker or calcium channel blocker in order to optimise heart rate control.

Achieving good heart rate control in atrial flutter can be challenging and – given the high success rates and low procedural risks – one would normally have a low threshold to recommend catheter ablation. DC cardioversion is an alternative option but is often not a permanent solution.

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