The heart rate control achieved with beta blockers is similar to that seen with verapamil and diltiazem. The rate-slowing effect of beta blockers is largely related to reduction of sympathetic tone. Esmolol is generally the preferred intravenous beta blocker because of its rapid onset.353 Care should be used in administering beta blockers for rate control in atrial flutter patients with decompensated heart failure or reactive airway disease.355 I B-NR Elective synchronized cardioversion is indicated in stable patients with well-tolerated atrial flutter when a rhythm-control strategy is being pursued.356 358 See Online Data and 17. Heart rates can be difficult to control in atrial flutter. Cardioversion for atrial flutter can be successful at lower energy levels than for AF.356 Anticoagulation issues for cardioversion are the same as those for patients with AF and are addressed in the 2014 AF guideline.10 Restoration of sinus rhythm is favored to avoid development of tachycardia-mediated cardiomyopathy, which is associated with a rapid ventricular response in atrial flutter. I B-NR Synchronized cardioversion is recommended for acute treatment of patients with atrial flutter who are hemodynamically unstable and do not respond to pharmacological therapies.75,208,356,359 See Online Data and 17. The ventricular rate in atrial flutter can be difficult to control with pharmacological therapy. In patients with any signs or symptoms of hemodynamic compromise attributed to atrial flutter, synchronized cardioversion (with appropriate considerations with regard to anticoagulation) should be pursued without delay. I C-LD Rapid atrial pacing is useful for acute conversion of atrial flutter in patients who have pacing wires in place as part of a permanent pacemaker or implantable cardioverter-defibrillator or for temporary atrial pacing after cardiac surgery.360 364 See Online Data and 17. 