What role do anticoagulants play in the management of atrial flutter, and how should I assess the risk of stroke in these patients?

Role of anticoagulants in atrial flutter: Anticoagulants are used in atrial flutter primarily to prevent stroke, as atrial flutter carries a similar risk of thromboembolism to atrial fibrillation. Stroke prevention with anticoagulation is recommended when the patient has a CHA2DS2-VASc score of 2 or more, or 1 in men, reflecting an elevated stroke risk. Direct-acting oral anticoagulants (DOACs) are preferred first-line options, including apixaban, dabigatran, edoxaban, and rivaroxaban, unless contraindicated, in which case vitamin K antagonists like warfarin are used. The benefits of anticoagulation generally outweigh the bleeding risks in most patients with atrial flutter who have elevated stroke risk scores. Antiplatelet therapy alone (e.g., aspirin) is not recommended solely for stroke prevention in these patients.

Stroke risk assessment: Stroke risk in patients with atrial flutter should be assessed using the CHA2DS2-VASc score, the same tool used for atrial fibrillation. This score considers factors such as congestive heart failure, hypertension, age, diabetes, stroke history, vascular disease, and sex category. Patients with a score of 2 or more are generally recommended to start anticoagulation. Bleeding risk should also be assessed using the ORBIT bleeding risk score to guide anticoagulation decisions and monitoring. Stroke and bleeding risks should be reassessed at least annually or when clinical circumstances change.