This handout is for atrial flutter complicated by acute embolic stroke. Your care team identified this based on: acute focal neuro deficit (nihss-scored) in patient with known or new atrial flutter — cardioembolic stroke until proven otherwise.
Other reasons your team may use this plan: cta-confirmed lvo + atrial flutter on monitor → emergent thrombectomy + delayed ac; atrial flutter newly diagnosed on telemetry / extended monitoring during stroke workup — cardioembolic etiology.
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 |
|---|---|---|---|---|
| alteplase | 0.9 mg/kg IV (max 90 mg); 10% bolus over 1 min then 90% over 60 min | IV | one-time | AHA/ASA 2024 Class I within 4.5 h (PMID 38483443); door-to-needle 45 min target |
| tenecteplase | 0.25 mg/kg IV bolus (max 25 mg) | IV | one-time | EXTEND-IA TNK (PMID 29694815) — non-inferior to alteplase, single bolus; AHA/ASA 2024 reasonable alternative |
| unfractionated_heparin | NO ROUTINE BRIDGING — only for mechanical valve / LV thrombus + small infarct + low bleed risk; if used: 60 U/kg bolus then 12 U/kg/h to PTT 1.5–2× control | IV | bolus + infusion (case-by-case only) | AHA/ASA 2024 — bridging with LMWH NOT recommended (PMID 38483443); UFH only in select high-thrombotic-risk + low-bleed situations |
| metoprolol_tartrate | 5 mg IV q5min × 3 then 25–50 mg PO BID | IV/PO | IV q5min × 3 → PO BID | AVN slowing for flutter; permissive HR control to support cerebral perfusion — ACC/AHA 2024 (PMID 38753446) |
| apixaban | 5 mg BID (2.5 mg BID if 2 of: ≥80 yr, ≤60 kg, Cr ≥1.5) — START AT DAY: small infarct (<1.5 cm) d1–3; medium infarct d6–7; large infarct (>3 cm or NIHSS ≥16) d10–14 | PO | BID | AHA/ASA 2024 (PMID 38483443) — DOAC preferred; ELAN (PMID 37162478) supports early initiation d3–4 for minor/moderate; ARISTOTLE foundational (PMID 21870978) |
| rivaroxaban | 20 mg with food (15 mg if CrCl 15–50) — START per infarct-size delay window | PO | once daily | ROCKET-AF (PMID 21830957); same delay-window approach |
| dabigatran | 150 mg BID (110 mg BID if ≥80 yr or higher bleed risk, where approved); avoid CrCl <30 | PO | BID | RE-LY (PMID 19717844) — idarucizumab available for emergent reversal |
| edoxaban | 60 mg daily (30 mg if CrCl 15–50, ≤60 kg, or P-gp inhibitor); avoid CrCl >95 | PO | once daily | ENGAGE-AF-TIMI-48 (PMID 24251369) |
| warfarin | 5 mg daily; INR target 2–3 | PO | daily | Mechanical valve / severe MS → only warfarin; renal failure DOAC-ineligible — ACC/AHA 2024 (PMID 38753446) |
| atorvastatin | 80 mg PO daily (high-intensity) | PO | daily | AHA/ASA 2024 Class I high-intensity statin for ischemic stroke; LDL <70 target (PMID 38483443) |
Plan: Atrial flutter + acute embolic stroke — acute reperfusion + delayed-AC (1–14 d per infarct size, NO LMWH bridge) + long-term DOAC pathway — AHA/ASA 2024 (PMID 38483443) + ACC/AHA 2024 AF (PMID 38753446) + ELAN (PMID 37162478)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Stroke clinic + cardiology + EP for flutter ablation candidacy; ambulatory ECG monitoring if cryptogenic; LDL <70 + statin; BP <130/80; cardiac rehab; long-term DOAC lifelong (CHA2DS2-VASc ≥2)
Guideline: 2024 AHA/ASA Acute Ischemic Stroke Guideline (Greenberg PMID 38483443) + 2024 ACC/AHA/ACCP/HRS AF + AFL Joint Guideline (Joglar PMID 38753446)