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Atrioventricular Nodal Reentry Tachycardia Treatment & Management

  • Author: Brian Olshansky, MD; Chief Editor: Jeffrey N Rottman, MD  more...
 
Updated: Apr 08, 2015
 

Approach Considerations

Rest, reassurance, sedation, and/or vagal maneuvers may terminate an attack of atrioventricular nodal reentry tachycardia (AVNRT). The successful management of an acute attack, however, depends on the symptoms, the presence of underlying heart disease, and the natural history of previous episodes.

In the presence of a wide-complex tachycardia, the institution of therapy should always follow a careful review of the patient's prior cardiac history, including left ventricular function and previous ECGs, which are helpful tools for defining the origin of the arrhythmia (ie, supraventricular vs ventricular).

The use of calcium channel blockers is contraindicated in patients with tachycardias of ventricular origin and may cause hemodynamic compromise and death.

Vagal maneuvers

To terminate AVNRT, try vagal maneuvers (eg, carotid sinus massage, exposure of the face to ice water, Valsalva maneuver) before initiating drug treatment. These maneuvers can also be tried after each pharmacologic approach. Vagal maneuvers are unlikely to work and should not be tried if hypotension is present. Sometimes, putting the patient in the Trendelenburg position facilitates termination with a vagal maneuver.

Direct-current synchronized cardioversion

Direct-current (DC) synchronized cardioversion is used to terminate an attack if the patient has hemodynamic compromise or if drug conversion fails and the patient continues to be symptomatic. However, DC cardioversion is rarely necessary for AVNRT.

Competitive atrial or ventricular pacing may be used if DC cardioversion is contraindicated (eg, if high doses of digitalis have been administered).

Diet

No specific recommendations or restrictions are necessary, but some patients' episodes are exacerbated by caffeine, theophylline, or theobromine in selected foods (coffee, tea, or chocolate, respectively). Alcohol may also be a trigger.

Activity

Advise the patient to rest during tachycardia, preferably in a supine position.

Consultations

Consultations include the following:

  • Cardiologist
  • Electrophysiologist

Transfer

Transfer to a facility capable of performing electrophysiologic studies and radiofrequency ablation may be needed.

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Pharmacologic Therapy

Drugs that can be used to terminate an attack include adenosine, calcium channel blockers (eg, diltiazem, verapamil), beta-blockers, and digitalis.

Adenosine

Adenosine is the first-line drug used for termination of AVNRT. In rare cases, the administration of adenosine may lead to atrial fibrillation or even asystole for a short period.

Adenosine administration should be given through a central, large bore intravenous (IV) needle, as it has a very short half-life. It should be followed by a saline flush and elevation of the extremity in which it is being injected. The initial dose is 6 mg followed by 12 mg and occasionally 18 mg. It should not be used in heart transplantation patients, it may be ineffective if given to a patient taking theophylline, and it may be potentiated by dipyridamole.

Preventive therapy

Preventive therapy is needed for frequent, prolonged, or highly symptomatic episodes that do not terminate spontaneously or for those that cannot be easily terminated by the patient. Drugs that are used for prevention of recurrence include long-acting beta-blockers, calcium channel blockers, and digitalis.

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Radiofrequency Catheter Ablation

Radiofrequency catheter ablation[6] of the reentrant circuit should be considered in patients who have frequent or highly symptomatic episodes, who do not want drug therapy, who cannot tolerate the drugs, or in whom drug therapy fails.

Radiofrequency catheter ablation is associated with cure rates of greater than 95%, with very low risk of AV block (< 1%) for patients with AVNRT.[6] This is an invasive procedure in which catheter electrodes are placed percutaneously via central veins into the heart. Tachycardia can be initiated by pacing and by programmed electrical stimulation delivered from the atria or the ventricles.

An ablation catheter electrode can be placed in the location of the slow AV nodal pathway, with radiofrequency energy delivered via the catheter to interrupt conduction via this pathway and thus eliminate the circuit.

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Contributor Information and Disclosures
Author

Brian Olshansky, MD Professor Emeritus of Medicine, Department of Internal Medicine, University of Iowa College of Medicine

Brian Olshansky, MD is a member of the following medical societies: American College of Cardiology, Heart Rhythm Society, Cardiac Electrophysiology Society, American Heart Association

Disclosure: Received honoraria from Guidant/Boston Scientific for speaking and teaching; Received honoraria from Medtronic for speaking and teaching; Received consulting fee from Guidant/Boston Scientific for consulting; Received consulting fee from BioControl for consulting; Received consulting fee from Boehringer Ingelheim for consulting; Received consulting fee from Amarin for review panel membership; Received consulting fee from sanofi aventis for review panel membership.

Coauthor(s)

Renee M Sullivan, MD, FACC Assistant Professor of Medicine, Department of Medicine, Division of Cardiovascular Medicine, University of Missouri Health System; Staff Physician, Electrophysiology, Harry S Truman Veterans Affairs Medical Center

Renee M Sullivan, MD, FACC is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Medical Association, Heart Rhythm Society, European Cardiac Arrhythmia Society, Group on Women in Medicine and Science

Disclosure: Nothing to disclose.

Chief Editor

Jeffrey N Rottman, MD Professor of Medicine, Department of Medicine, Division of Cardiovascular Medicine, University of Maryland School of Medicine; Cardiologist/Electrophysiologist, University of Maryland Medical System and VA Maryland Health Care System

Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association, Heart Rhythm Society

Disclosure: Nothing to disclose.

Acknowledgements

Marco A Barzallo, MD Consulting Staff, HeartCare Midwest, SC

Disclosure: Nothing to disclose.

Mukesh Garg, MD, MRCP Assistant Professor, Department of Internal Medicine, Section of Cardiology, Truman Medical Center, University of Missouri at Kansas City

Disclosure: Nothing to disclose.

Shamila Garg, MD

Disclosure: Nothing to disclose.

Marina Hannen, MD  Clinical Assistant Professor, Department of Cardiology, Section of Cardiovascular Diseases, University of Kansas Medical Center; Consulting Staff, Mid-American Cardiology Associates

Disclosure: Nothing to disclose.

Russell F Kelly MD, Assistant Professor, Department of Internal Medicine, Rush Medical College; Chairman of Adult Cardiology and Director of the Fellowship Program, Cook County Hospital

Russell F Kelly is a member of the following medical societies: American College of Cardiology

Disclosure: Nothing to disclose.

Annette Quick, MD, Medical Director, Cardiovascular Care Unit, Associate Professor, Department of Medicine, University of Missouri-Kansas City School of Medicine

Disclosure: Nothing to disclose.

Chirag M Sandesara, MD, FACC Virginia Cardiovascular Associates, Cardiac Rhythm Care

Chirag M Sandesara, MD, FACC is a member of the following medical societies: American College of Cardiology, American College of Physicians-American Society of Internal Medicine, American Heart Association, American Medical Association, and Heart Rhythm Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD   Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine. 7th ed. Philadelphia, Pa: WB Saunders; 2004.

  2. Janse MJ, Anderson RH, McGuire MA, Ho SY. "AV nodal" reentry: Part I: "AV nodal" reentry revisited. J Cardiovasc Electrophysiol. 1993 Oct. 4(5):561-72. [Medline].

  3. Hanninen M, Yeung-Lai-Wah N, Massel D, Gula LJ, Skanes AC, Yee R, et al. Cryoablation versus RF ablation for AVNRT: A meta-analysis and systematic review. J Cardiovasc Electrophysiol. 2013 Dec. 24(12):1354-60. [Medline].

  4. Gursoy S, Steurer G, Brugada J, et al. Brief report: the hemodynamic mechanism of pounding in the neck in atrioventricular nodal reentrant tachycardia. N Engl J Med. 1992 Sep 10. 327(11):772-4. [Medline].

  5. Fogoros RN. Electrophysiologic Testing (Practical Cardiac Diagnosis). 3rd ed. London, UK: Blackwell Science; 1999.

  6. Jackman WM, Beckman KJ, McClelland JH, et al. Treatment of supraventricular tachycardia due to atrioventricular nodal reentry, by radiofrequency catheter ablation of slow-pathway conduction. N Engl J Med. 1992 Jul 30. 327(5):313-8. [Medline].

 
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Electrophysiological mechanism of atrioventricular nodal reentry tachycardia.
Atypical atrioventricular nodal reentry tachycardia.
Typical atrioventricular nodal reentry tachycardia.
 
 
 
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