This handout is for atrial flutter / atrial tachycardia — post-cardiac-surgery (poaf). Your care team identified this based on: new atrial flutter on telemetry postoperative day 2–4 after cabg, valve surgery, or maze — peak poaf onset window (sts 2024).
Other reasons your team may use this plan: atrial flutter with rvr after mitral surgery — incidence 30–60% per lapar jtcvs 2014; coordinated with cardiac surgery team; recurrent atrial flutter after surgical maze procedure — incidence 50–70% in early postop period; reflects atrial scar substrate plus inflammation.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| esmolol | 0.5 mg/kg IV bolus over 1 min then 50–300 µg/kg/min infusion; titrate HR 80–110 | IV | continuous; titrate | AATS 2014 first-line short-acting BB for postop RVR; titratable, easily reversible — ideal for evolving postop hemodynamics (PMID 24290998) |
| metoprolol | 5 mg IV q5 min × 3 doses, then 25–100 mg PO BID | IV/PO | IV bolus then PO BID | AATS 2014 + ACC/AHA 2024 (PMID 38753446) — preferred BB for chronic rate control postop |
| diltiazem | 0.25 mg/kg IV bolus over 2 min then 5–15 mg/h infusion; 120–360 mg PO daily | IV/PO | bolus + infusion or daily PO | AVN slowing alternative when BB contraindicated; AVOID if EF <40 — ACC/AHA 2024 (PMID 38753446) |
| amiodarone | 150 mg IV bolus over 10 min then 1 mg/min × 6h then 0.5 mg/min × 18h; 200 mg PO daily × 4–6 wk maintenance | IV/PO | load + daily PO | AATS 2014 + STS 2024 + ACC/AHA 2024 (PMID 38753446); pulm/thyroid/LFT monitoring; 4–6 wk taper postop |
| colchicine | 0.5 mg PO BID (≥70 kg) or 0.5 mg PO daily (<70 kg) × 1 mo postop | PO | daily/BID × 1 mo | COPPS-2 (Imazio JAMA 2014 PMID 25268438) — reduces POAF AND post-pericardiotomy syndrome; SHaPED 2024 colchicine post-CABG extension |
| enoxaparin | 1 mg/kg SC BID (CrCl >30) or 1 mg/kg SC daily (CrCl 15–30) | SC | BID or daily per CrCl | Bridge AC for persistent POAF >48h; transition to DOAC at 24 h after last LMWH dose — ACC/AHA 2024 (PMID 38753446) |
| apixaban | 5 mg BID (2.5 mg BID if 2 of: ≥80 yr, ≤60 kg, Cr ≥1.5) | PO | BID | ARISTOTLE (PMID 21870978) preferred DOAC; 3-mo time-limited if reverts AND no recurrence on follow-up Holter — ACC/AHA 2024 Class I (PMID 38753446) |
| warfarin | 5 mg daily; INR target 2–3 | PO | daily | Mechanical valve / severe MS / DOAC-ineligible — ACC/AHA 2024 (PMID 38753446) |
| magnesium sulfate | 2 g IV over 15 min then 1–2 g/h titrate Mg 2.0–2.5 | IV | continuous | AATS 2014 (PMID 24290998) — Mg repletion FOUNDATIONAL for POAF prevention and treatment |
| potassium_chloride | 40 mEq IV over 4h or PO 40 mEq q2-4h titrate K 4.0–4.5 | IV/PO | as needed | AATS 2014 — K target 4.0–4.5 foundational for POAF management |
Plan: Post-cardiac-surgery atrial flutter — IV BB rate control + amiodarone rhythm bridge + AC bridge with planned 3-mo duration if reverts; foundational K + Mg repletion + colchicine for post-pericardiotomy co-management — ACC/AHA 2024 (Joglar PMID 38753446); AATS 2014 (Frendl PMID 24290998); STS 2024; COPPS-2 (Imazio PMID 25268438)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Cardiac surgery + cardiology follow-up at 2 wks postop with ECG; cardiology at 4–6 wk for rhythm assessment + AC continuation decision; Holter at 3 mo to document sinus maintenance; AC STOP at 3 mo if reverts AND no recurrence on Holter; cardiac rehab booked; post-pericardiotomy syndrome surveillance with NSAID + colchicine if effusion present
Guideline: 2024 ACC/AHA/ACCP/HRS AF + AFL Joint Guideline (Joglar) + AATS 2014 POAF Management Consensus + STS 2024 Post-Cardiac-Surgery AF + COPPS-2 colchicine + ARISTOTLE apixaban