Ongoing Management: Recommendations I B-NR Acute antithrombotic therapy is recommended in patients with atrial flutter to align with recommended antithrombotic therapy for patients with AF.365 See Online Data and 17. The risk of stroke associated with AF is well established, and several RCTs have demonstrated the efficacy of anticoagulation for stroke prevention in patients with additional risk factors.366 Anticoagulation has also been shown to prevent stroke when administered during the weeks immediately before and after cardioversion.367 Whether atrial flutter carries a risk of stroke similar to that in patients with AF has been debated in the past but is now supported by limited evidence from mechanistic, observational, and prospective studies that include patients primarily with atrial flutter.365 369 Several reports have suggested that the risk of stroke in patients with atrial flutter is mitigated by anticoagulation. Meta-analysis of 13 studies of patients undergoing cardioversion of atrial flutter reported short-term stroke risks ranging from 0% to 7%, and the thromboembolism rate in patients with sustained flutter Other studies have reported similar risk and effectiveness of anticoagulation.369 Therefore, on the basis of the available data, recommendations for antithrombotic therapy for patients with atrial flutter are similar to those for patients with AF.10 IIa B-R Intravenous amiodarone can be useful for acute control of the ventricular rate (in the absence of pre-excitation) in patients with atrial flutter and systolic heart failure, when beta blockers are contraindicated or See Online Data and 17. Amiodarone may be useful for rate control in non pre-excited atrial flutter because of its slowing of conduction through the AV node and prolongation of AV nodal refractoriness. Because it has less negative inotropic effect than beta blockers, diltiazem, and verapamil and may produce less hypotension, it may be preferred in critically ill patients or in those with tenuous hemodynamic stability. 