This handout is for pre-excited atrial flutter (wpw) — dccv / procainamide; av-nodal blockers absolutely contraindicated. Your care team identified this based on: palpitations, presyncope or syncope in a patient with known wpw / a delta wave on prior ecg — pre-excited atrial flutter/af until proven otherwise (vf risk).
Other reasons your team may use this plan: very fast (>200-250 bpm), broad-complex, often irregular tachycardia — pre-excited atrial flutter/af; distinguish from polymorphic vt and svt with aberrancy; ecg showing flutter/fibrillatory atrial activity conducting with variable broad pre-excited qrs morphology — antegrade accessory-pathway conduction; hypotension / shock / pulmonary oedema / ischaemia with a wide irregular tachycardia — unstable pre-excited tachyarrhythmia requiring immediate synchronised dccv.
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 |
|---|---|---|---|---|
| Synchronised DC cardioversion | 100-200 J biphasic synchronised, escalate as needed (immediate if unstable; default even in many stable patients given VF risk) | N/A | as needed; immediate if haemodynamic instability | ACLS 2020 + SVT guidelines — definitive, fastest, safest termination; avoids the VF risk of AV-nodal blockade entirely |
| procainamide | 15-17 mg/kg IV at ≤20-50 mg/min until arrhythmia terminates, hypotension, QRS widens >50%, or max dose; then 1-4 mg/min infusion | IV | loading then infusion, monitored | 2015 ACC/AHA/HRS + 2019 ESC SVT — prolongs accessory-pathway refractoriness and slows pre-excited conduction; preferred stable-patient agent; stop for hypotension or >50% QRS widening |
| ibutilide | 1 mg IV over 10 min (0.01 mg/kg if <60 kg), may repeat once after 10 min; continuous ECG ≥4 h | IV | once, may repeat ×1 | 2019 ESC SVT — effective for pre-excited AF/flutter; correct K/Mg first; torsades risk → monitor QT ≥4 h with defibrillator available |
| AVOID adenosine | DO NOT GIVE | N/A | N/A | Transient AV-nodal block can increase antegrade accessory-pathway conduction and precipitate AF→VF; contraindicated in pre-excited AF/flutter (2015 ACC/AHA/HRS) |
| AVOID IV diltiazem/verapamil + beta-blockers | DO NOT GIVE | N/A | N/A | AV-nodal blockade preferentially channels conduction down the accessory pathway → very rapid ventricular rates and VF; contraindicated (2019 ESC SVT; 2020 ESC AF) |
| AVOID digoxin | DO NOT GIVE | N/A | N/A | Shortens accessory-pathway refractory period and slows the AV node → accelerated pre-excited conduction; contraindicated |
| AVOID intravenous amiodarone | DO NOT GIVE acutely | N/A | N/A | IV amiodarone can cause AV-nodal block + hypotension and has been associated with acceleration to VF in pre-excited AF — avoided acutely per 2019 ESC SVT / 2020 ESC AF (DCCV or procainamide preferred) |
| Accessory-pathway catheter ablation (definitive) | EP study + radiofrequency/cryo ablation of the accessory pathway; confirm bidirectional block | N/A | definitive, post-stabilisation | 2015 ACC/AHA/HRS + 2019 ESC SVT — Class I after a pre-excited AF/flutter event; curative and removes the VF substrate |
Plan: Pre-excited atrial flutter — synchronised DCCV if unstable; IV procainamide/ibutilide if stable; AV-nodal blockers ABSOLUTELY contraindicated (2015 ACC/AHA/HRS SVT; 2019 ESC SVT; 2020 ESC AF)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Electrophysiology: accessory-pathway ablation (curative; Class I post pre-excited AF/flutter) — confirm bidirectional pathway block; sports/occupational clearance only after successful ablation or reassuring risk stratification; family screening if SCD history; document lifelong AV-nodal-blocker avoidance until pathway eliminated; anticoagulation per CHA2DS2-VASc if AF component persists
Guideline: 2015 ACC/AHA/HRS SVT Guideline + 2019 ESC SVT Guideline + 2020 ESC AF Guideline + 2017 AHA/ACC/HRS VA/SCD