Patient handout

Typical (CTI-dependent) atrial flutter

PRODUCTION

1. Your condition

This handout is for typical (cti-dependent) atrial flutter. Your care team identified this based on: sawtooth flutter waves negative in ii/iii/avf (counterclockwise cti-dependent reentry).

Other reasons your team may use this plan: palpitations with regular narrow-complex tachy at hr ~150 (2:1 av conduction signature); recurrent typical flutter after prior cardioversion → cti ablation candidate.

2. Your medications

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
metoprolol_tartrate	5 mg IV q5min × 3 then 25–50 mg PO BID	IV/PO	IV q5min × 3 → PO BID	AVN slowing for 2:1 conducted typical flutter; HR target 80–110 — ACC/AHA 2024 (PMID 38753446)
metoprolol_succinate	25–50 mg PO daily	PO	once daily	Long-acting BB bridge to CTI ablation — ACC/AHA 2024
diltiazem	0.25 mg/kg IV bolus → 5–15 mg/h infusion; 120–360 mg PO daily	IV/PO	IV bolus + infusion → PO daily	AVN slowing alternative; AVOID in HFrEF EF<40 — ACC/AHA 2024 (PMID 38753446)
ibutilide	1 mg IV over 10 min (0.01 mg/kg if <60 kg); may repeat ×1	IV	single dose, may repeat once	Ibutilide ~60% conversion rate for typical flutter (vs ~30% for AF); monitor QT 4 h post-dose for torsades (~3% risk) — 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	AC same as AF; mandatory 4-week post-CV AC regardless of score — ACC/AHA 2024 Class I (PMID 38753446); ARISTOTLE (PMID 21870978)
rivaroxaban	20 mg with food (15 mg if CrCl 15–50)	PO	once daily	X-VeRT (PMID 24837375) — peri-CV efficacy = warfarin; ROCKET-AF foundational

Plan: Typical CTI-dependent atrial flutter — rate control + AC + curative CTI ablation pathway — ACC/AHA 2024 (Joglar PMID 38753446); Calkins HRS/EHRA/ECAS 2007 (PMID 17572388)

3. When to call your provider

Contact your care team if any of the following happen:

Recurrent typical flutter despite ablation → repeat EP mapping — HRS 2007
New AF after successful CTI ablation (~25%) → AF management via cardio.afib.core.v1
Stroke / TIA on AC → workup + consider switch — ACC/AHA 2024

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Typical CTI flutter with SBP <90, AMS, ongoing ischemia, or pulmonary edema → synchronized DCCV 50–100 J biphasic now(life-threatening)
Hypotension + new pericardial effusion within hours of CTI ablation → emergent pericardiocentesis(life-threatening)
Fever + chest pain + new neurologic deficit 2–6 weeks post-ablation (rare in CTI but reported) → emergency surgical evaluation(life-threatening)
GI bleed, intracranial bleed, or major bleed during mandatory 4-week post-CV AC window
Persistent uncontrolled RVR despite max AVN blockade + failed CTI ablation + symptomatic — consider AV node ablation + permanent pacemaker

5. Follow-up

EP for CTI ablation within 4–8 weeks (Class I); cardiology q3–6 mo; AC continuation per CHA2DS2-VASc; lifestyle (alcohol, weight, OSA); post-ablation 4-week ECG + Holter at 3 mo

6. Sources

Guideline: 2024 ACC/AHA/ACCP/HRS AF + AFL Joint Guideline (Joglar Circulation 2024 PMID 38753446); ESC 2024 AF (Van Gelder EHJ 2024 PMID 39050851); HRS/EHRA/ECAS 2007 catheter ablation expert consensus (Calkins PMID 17572388)