Atrial Fibrillation Guidelines

Updated: Nov 18, 2019
  • Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jeffrey N Rottman, MD  more...
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Guidelines

Atrial Fibrillation Classification

Guideline contributor: Noel G Boyle, MB, BCh, MD, PhD, Professor of Medicine, UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center.

Atrial fibrillation classification

In 2014, the American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) released updated guidelines for the management of patients with atrial fibrillation (AF). These guidelines supersede the AF guideline published in 2006 and updated in 2011. The guidelines provide the following revised classification schema, based on duration of episodes [1]

  • Paroxysmal AF: Episodes of AF that terminate spontaneously or with intervention within 7 days; may recur with variable frequency

  • Persistent AF: Episodes of continuous AF that last more than 7 days and do not self-terminate

  • Long-standing persistent AF: Episodes of continuous AF that last more than 12 months

  • Permanent AF: Applies when a joint physician/patient decision has been made to accept the presence of AF and stop further attempts to restore and/or maintain sinus rhythm (as this represents clinical acceptance rather than an inherent pathophysiological attribute of AF, it is understood that acceptance of AF may change as symptoms, efficacy of interventions, and patient/physician preferences evolve)

  • Nonvalvular AF: AF in the absence of rheumatic mitral valve disease, a prosthetic heart valve, or mitral valve repair

It is further noted that episodes often increase in frequency and duration over time. In addition, the term “lone AF” to identify AF in typically younger patients without structural heart disease, hypertension, or diabetes mellitus is deemed potentially confusing and should not be used to guide treatment decisions. [1]

The European Society of Cardiology (ESC) utilizes a similar classification schema published in its 2010 guidelines. The ESC included one additional characterization, silent AF (asymptomatic), which can manifest as AF-related complications such as ischemic stroke or tachycardiomyopathy, or is diagnosed incidentally on electrocardiography (ECG). Any form of AF may be silent or asymptomatic. [148]

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Stroke Risk Assessment

Guidelines have been issued by the following organizations for prevention of stroke in atrial fibrillation (AF) patients:

  • 2014 American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS)
  • 2012 European Society of Cardiology (ESC)
  • 2014 American Academy of Neurology (AAN)
  • 2012 American College of Chest Physicians (ACCP)

All major guidelines note that one of the major management decisions in AF is determining the risk of stroke and the appropriate anticoagulation regimen for low-, intermediate-, and high-risk patients. For each anticoagulant, the benefit in terms of stroke reduction must be weighed against the risk of serious bleeding, with the risk-benefit ratio generally considered not advantageous in low-risk patients with AF. Thus, the guidelines stress that clinical judgment and patient preferences should play a major role in shared decision making. [1, 97, 149, 150]

The CHADS2 score (Cardiac failure, Hypertension, Age >75 years, Diabetes, prior Stroke or TIA [transient ischemic attack]) is the most widely used algorithm to determine yearly thromboembolic risk. Two points are assigned for a history of stroke or TIA, and 1 point is given for age older than 75 years or a history of hypertension, diabetes, or heart failure. [65]

The ACCP bases its recommendations for antithrombotic therapy in patients with nonvalvular atrial fibrillation (NVAF) on the CHADS2 score, as follows [150] :

  • CHADS 2 score = 0 (low risk): No antithrombotic therapy
  • CHADS 2 score ≥1 (intermediate or high risk): Oral antithrombotic therapy

However, the 2014 AHA/ACC/HRS and 2012 updated ESC guidelines both recommend that the CHADS2 score be replaced with the more comprehensive CHA2DS2-VASc score. [1, 149] In this scoring system, points are assigned as follows [66] :

  • Congestive heart failure (CHF): 1 point
  • Hypertension: 1 point
  • Age ≥75 years: 2 points
  • Diabetes: 1 point
  • Stroke, TIA, or thromboembolism history: 2 points
  • Vascular disease (myocardial infarction [MI], peripheral arterial disease, aortic plaque): 1 point
  • Age 65-74 years: 1 point
  • Sex category (female sex): 1 point

The AHA/ACC/HRS further recommends that antithrombotic therapy should be based on the risk of thromboembolism irrespective of whether the AF pattern is paroxysmal, persistent or permanent. [1]

In 2014, the American Heart Association (AHA) also issued joint guidelines with the American Stroke Association (ASA) for the primary prevention of stroke, which included specific recommendations for stroke prevention in patients with AF. The main advantage of the CHA2DS2-VASc score (range, 0-9) is that it provides significantly improved risk prediction for individuals at low to moderate risk compared with the CHADS2 (scores of 0 or 1), particularly for elderly women. [151]

The AHA/ACC/HRS recommendations for antithrombotic therapy in patients with AF, based on CHA2DS2-VASc scores, are as follows [1] :

  • NVAF and CHA 2DS 2-VASc score = 0: No antithrombotic therapy
  • NVAF and CHA 2DS 2-VASc score = 1: No antithrombotic therapy or oral antithrombotic therapy
  • Prior stroke, TIA or CHA 2DS 2-VASc Score ≥2: Oral antithrombotic therapy

The ESC offers varying recommendations for patients with AF based on CHA2DS2-VASc scores, as follows [149] :

  • CHA 2DS 2-VASc score = 0: No antithrombotic therapy
  • CHA 2DS 2-VASc score = 1: Oral anticoagulants
  • CHA 2DS 2-VASc score ≥2: Oral anticoagulants

The shift from the CHADS2 score to the CHA2DS2-VASc score has not been without controversy. The number of patients eligible for oral anticoagulant therapy in the United States is estimated to increase by nearly 1 million, raising concerns about the associated increase in bleeding complications. An analysis by O’Brien and colleagues concluded that using the 2014 AHA/ACC/HRS recommendations to guide the management of AF would result in 98.5% of patients 65 years of age and older and 97.7% of women with AF receiving a definitive recommendation for oral anticoagulant therapy. [152]

The 2014 AAN revised guidelines for stroke prevention in NVAF recommend use of risk stratification to aid in clinical decision making, but do not recommend the use of any specific tool. Furthermore, the guidelines caution against use of strictly interpreted thresholds as definitive indicators for which patients require anticoagulation therapy. Additional recommendations for patient selection included the following [97] :

  • Anticoagulation therapy should be offered to all patients with NVAF and a history of ischemic attack or stroke
  • Anticoagulation therapy should not be offered to patients with NVAF who lack additional risk factors; these patients may be offered aspirin therapy or no antithrombotic therapy
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Antithrombotic Therapy

The major guidelines vary considerably in their recommendations for antithrombotic therapy. See the table below.

Table. Antithrombotic Therapy Recommendations for Atrial Fibrillation (Open Table in a new window)

Issuing Organization Year Patient Groups Antithrombotic Therapy
American Heart Association/American College of Cardiology/ Heart Rhythm Society (AHA/ACC/HRS) [1] 2014
  • AF with mechanical heart valve
  • With prior stroke, TIA or CHA 2DS 2-VASc score ≥2
  • NVAF and CHA 2DS 2-VASc score ≥2
  • NVAF with CHA 2DS 2-VASc score ≥2 and end-stage CKD or on hemodialysis
  • NVAF with CHA 2DS 2-VASc score ≥2 and moderate to severe CKD
  • All patients
  • Warfarin therapy; target INR, 2.0-3.0 or 2.5-3.5 based on type and location of prosthesis
  • Bridging therapy with unfractionated heparin or LMWH for patients undergoing procedures that require interruption of warfarin. Decisions on bridging therapy should balance the risks of stroke and bleeding.
  • Oral anticoagulants: Warfarin (INR 2.0-3.0), dabigatran, apixaban, or rivaroxaban
  • Warfarin (INR 2.0-3.0); if unable to maintain a therapeutic INR level with warfarin, use of a direct thrombin or factor Xa inhibitor (dabigatran, rivaroxaban, or apixaban)
  • Warfarin (INR 2.0-3.0); direct thrombin or factor Xa inhibitors are not recommended
  • Reduced doses of direct thrombin or factor Xa inhibitors may be considered (eg, dabigatran, rivaroxaban, apixaban), but safety and efficacy have not been established
  • In patients receiving warfarin, the INR should be determined at least weekly during initiation of antithrombotic therapy and at least monthly when anticoagulation (INR in range) is stable
  • Periodic reevaluation of the need and choice of anti-thrombotic therapy to reassess stroke and bleeding risks
American Heart Association/American Stroke Association (AHA/ASA) [151] 2014
  • Valvular AF/ CHA 2DS 2-VASc score ≥2
  • NVAF// CHA 2DS 2-VASc score ≥2 and low risk for hemorrhagic complications
  • NVAF, CHA 2DS 2-VASc score = 1, and low risk for hemorrhagic complications
  • Warfarin therapy; target INR, 2.0-3.0
  • Oral anticoagulant (warfarin, dabigatran, apixaban, or rivaroxaban) individualized based on patient risk factors (particularly risk for intracranial hemorrhage), cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics.
  • No antithrombotic therapy, anticoagulant therapy, or aspirin therapy may be considered
American Academy of Neurology (AAN) [97] 2014
  • NVAF and history of TIA or stroke; age >75 years, if no history of unprovoked bleeding or intracranial hemorrhage; patients with dementia or occasional falls; however in patients with moderate to severe dementia or frequent falls, risk-benefit ratio is uncertain
  • Patients at moderate stroke risk in developing countries where newer anticoagulants are unavailable
  • Warfarin, target INR 2.0 to 3.0
  • Dabigatran, rivaroxaban, or apixaban (preferred) if at high risk for intracranial bleeding or unable to submit to frequent periodic INR testing
  • Apixaban, if at increased risk for gastrointestinal bleeding
  • Triflusal 600 mg/day plus moderate-intensity anticoagulation (INR 1.25–2.0) with acenocoumarol is likely more effective than acenocoumarol alone at the higher INR (2.0-3.0)
American College of Chest Physicians (ACCP) [150] 2012 NVAF intermediate risk (CHADS2 score = 1) or high risk (CHADS2 score ≥2)
  • Oral anticoagulants: dabigatran 150 mg BID preferred over warfarin (target INR range, 2.0-3.0)
  • Patients who are unsuitable for or choose not to take an oral anticoagulant (for reasons other than concerns about major bleeding): combination therapy with aspirin and clopidogrel
European Society of Cardiology (ESC) [149] 2012
  • CHA 2DS 2-VASc score = 0, and females aged < 65 years with CHA 2DS 2-VASc score = 1
  • CHA 2DS 2-VASc score = 1
  • CHA 2DS 2-VASc score ≥2
  • All patients
  • Patients who refuse oral anticoagulants
  • No antithrombotic therapy
  • Oral anticoagulants: Warfarin (INR 2.0-3.0) or dabigatran or rivaroxaban or apixaban based on assessment of risk of bleeding
  • Oral anticoagulants: Dabigatran or rivaroxaban or apixaban preferred over warfarin (INR 2.0-3.0)
  • When dabigatran is considered, 150 mg BID preferred; 110 mg BID is preferred for ages ≥80 years, concomitant use of interacting drugs, high bleeding risk or moderate renal impairment
  • When rivaroxaban is considered, 20 mg OD preferred; 15 mg OD is preferred for those with high bleeding risk or moderate renal impairment
  • Baseline and subsequent annual assessment of renal function (by CrCl) is recommended in patients following initiation of any novel oral anticoagulant (dabigatran, rivaroxaban, and apixaban), and 2-3 times per year in those with moderate renal impairment; novel oral anticoagulants are not recommended in patients with severe renal impairment (CrCl < 30 mL/min)
  • Antiplatelet therapy should be considered, using combination therapy with aspirin 75–100 mg plus clopidogrel 75 mg daily (where there is a low risk of bleeding) or—less effectively—aspirin 75–325 mg daily

Note: Edoxaban was approved by the FDA in January 2015 for use as an oral anticoagulant in atrial fibrillation.

AF = atrial fibrillation; BID = twice daily; CKD = chronic kidney disease; CrCl = creatinine clearance; INR = international normalized ratio; LMWH = low-molecular-weight heparin; NVAF = nonvalvular atrial fibrillation; OD = before bedtime; TIA = transient ischemic attack.

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Rate Control

The 2017 American Academy of Family Physicians updated guidelines on the pharmacologic management of newly diagnosed atrial fibrillation (AF) include the following recommendations for patients with AF [153] :

  • Rate control is preferred to rhythm control for most patients with AF, with preferred rate-control options including non-dihydropyridine calcium channel blockers and beta-blockers. However, rhythm control may be considered for some patients on the basis of their symptoms, exercise tolerance, and preferences.

  • Lenient rate control (< 110 beats per minute [bpm]) is preferred over strict rate control (< 80 bpm).

  • Clinicians should discuss stroke and bleeding risks with all patients considering anticoagulation, as well as consider using continuous CHADS2 or CHA2 DS2 -VASc for predicting stroke risk and HAS-BLED for prediction of bleeding risk.

  • Chronic anticoagulation (eg, warfarin, apixaban, dabigatran, edoxaban, rivaroxaban) is recommended unless patients have a low stroke risk (CHADS2< 2) or have specific contraindications. Selection of the anticoagulation therapy should be based on patient preferences and history.

  • Dual treatment with anticoagulant and antiplatelet therapy is strongly not recommended in most patients with AF.

The 2014 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) guidelines include the following recommendations for control of ventricular rate in patients with AF [1] :

  • Beta-blockers or non-dihydropyridine calcium channel blockers are first-line agents for paroxysmal, persistent or permanent AF.

  • Intravenous (IV) beta-blockers or non-dihydropyridine calcium channel blockers may be used to slow ventricular heart rate in an acute setting in patients without preexcitation; in hemodynamically unstable patients, electrical cardioversion is indicated.

  • Consider IV amiodarone for rate control in critically ill patients without preexcitation if the condition limits the use of beta-blockers or calcium channel blockers.

  • In patients with AF symptoms during activity, assess heart rate control during exertion, adjusting drug treatment as needed.

  • Heart rate control (defined as < 80 bpm at rest) may be considered for less symptomatic patients with AF; a more lenient rate-control strategy (< 110 bpm at rest) is reasonable when patients remain asymptomatic and left ventricular (LV) systolic function is preserved.

  • In patients with inadequate ventricular rate control despite drug therapy, atrioventricular (AV) nodal ablation and pacemaker implantation may be considered.

  • AV nodal ablation should not be performed without prior attempts to achieve rate control with medications.

  • Non-dihydropyridine calcium channel blockers are contraindicated in decompensated heart failure.

  • With preexcitation syndrome and AF, non-dihydropyridine calcium channel blockers, digoxin, and IV amiodarone are contraindicated.

  • Dronedarone should not be used in patients with permanent AF or class III or IV heart failure.

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Cardioversion

The 2014 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) guidelines provide the following recommendations regarding cardioversion of atrial fibrillation (AF) [1] :

  • AF of ≥48 hours’ duration, or when the duration is unknown: Warfarin anticoagulation (international normalized ratio [INR] 2-3) for at least 3 weeks before and 4 weeks after cardioversion, regardless of the CHA2DS2-VASc score and the cardioversion method (electrical or pharmacological) used; anticoagulation with dabigatran, rivaroxaban, or apixaban is also reasonable

  • AF of ≥48 hours’ duration, or when the duration is unknown, requiring immediate cardioversion for hemodynamic instability: Anticoagulation should be administered as soon as possible and continued for 4 weeks after cardioversion

  • AF with high risk of stroke and < 48 hours’ duration: Administration of IV heparin or low molecular weight heparin (LMWH), factor Xa inhibitor, or direct thrombin inhibitor as soon as possible before and immediately after cardioversion, followed by long-term anticoagulation therapy

  • AF with low risk of stroke and < 48 hours’ duration: Administration of either IV heparin or LMWH, factor Xa or direct thrombin inhibitor or no antithrombotic therapy may be considered for cardioversion, without the need for postcardioversion oral anticoagulation therapy

  • For AF of any duration, long-term anticoagulation therapy should be based on the patient’s stroke risk profile

  • AF or atrial flutter of ≥48 hours’ duration: For conversion of AF of ≤7 days, agents with proven efficacy include flecainide, ibutilide, propafenone and, to a lesser degree, amiodarone

  • For conversion of AF lasting 7-90 days, agents with proven efficacy include amiodarone, ibutilide, flecainide, and propafenone

  • For conversion of AF lasting more than 90 days, oral propafenone, amiodarone, and dofetilide have been shown to be effective at converting persistent AF to normal sinus rhythm

  • Propafenone or flecainide in addition to a beta-blockers or non-dihydropyridine calcium channel antagonists is reasonable for termination of AF outside the hospital, once this treatment has been observed to be safe in a monitored setting for selected patients (“pill-in-the-pocket”)

  • Dofetilide therapy should not be initiated out of hospital because of the risk of torsade de pointes

  • Direct current cardioversion (DCC) is indicated when rapid ventricular rate does not respond promptly to medications in patients with AF and ongoing myocardial ischemia, hypotension or heart failure

  • Immediate DCC in preexcitation with rapid tachycardia or hemodynamic instability

NOTE: Repeated cardioversions may be undertaken in patients with persistent AF, provided that sinus rhythm can be maintained for a clinically meaningful period between cardioversion procedures; severity of AF symptoms and patient preference should be considered before initiation of a strategy requiring serial cardioversions

In general, the European Society of Cardiology (ESC) recommendations for cardioversion concur with the AHA/ACC/HRS guidelines. Many of the differences between the guidelines involve the use of vernakalant, which was approved for use in European Union in 2010 but has not been approved by the US Food and Drug Administration. Additional and/or variant ESC recommendations include the following [149] :

  • In the absence of structural heart disease, IV flecainide, propafenone, ibutilide, or vernakalant
  • In patients with risk factors for stroke or AF recurrence, oral anticoagulant therapy should be continued lifelong, irrespective of the apparent maintenance of sinus rhythm following cardioversion
  • In patients with AF ≤7 days and moderate structural heart disease, IV vernakalant may be considered
  • Vernakalant should be used with caution in patients with NYHA class I–II heart failure

The ESC guidelines note that vernakalant is contraindicated in patients with any of the following:

  • Hypotension (systolic blood pressure < 100 mm Hg)
  • Recent (30 days) acute coronary syndrome
  • New York Heart Association (NYHA) class III and IV heart failure
  • Severe aortic stenosis
  • QT interval prolongation (uncorrected QT >440 ms)
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Maintaining Sinus Rhythm

The 2014 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) guidelines include the following recommendations for the prevention of atrial fibrillation (AF) and maintenance of sinus rhythm [1] :

  • Precipitating or reversible causes of AF should be treated before initiation of antiarrhythmic drug therapy; antiarrhythmic drug therapy can be considered for treatment of tachycardia-induced cardiomyopathy

  • Antiarrhythmic drugs include amiodarone, dofetilide, dronedarone, flecainide, propafenone, and sotalol; drug selection should be based on underlying heart disease and comorbidities

  • Consider risks, including proarrhythmia, before initiating antiarrhythmic drug treatment

  • Amiodarone should be used only after consideration of its potential toxicities and risks, and when other agents have failed or are contraindicated

  • Discontinue antiarrhythmic drugs, including dronedarone, when AF becomes permanent

  • Dronedarone is contraindicated for treatment of AF in patients with New York Heart Association (NYHA) class III and IV heart failure or patients who have had an episode of decompensated heart failure in the past 4 weeks

The European Society of Cardiology (ESC) recommendations for maintenance of sinus rhythm are similar to those in the AHA/ACC/HRS. [149]

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Catheter Ablation

Both the 2014 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) and 2012 European Society of Cardiology updated guidelines suggest a more prominent role for radiofrequency ablation in the treatment of atrial fibrillation (AF), including its use as first-line therapy in recurrent symptomatic paroxysmal or persistent AF. [1, 149]

According to AHA/ACC/HRS guidelines, AF catheter ablation is contraindicated for patients who cannot be treated with anticoagulant therapy during and after the procedure and should not be performed with the sole intent of eliminating the need for anticoagulation. [1]

The 2017 HRS/EHRA/ECAS/APHRS/SOLAECE (HRS, European Heart Rhythm Association, European Cardiac Arrhythmia Society, Asia Pacific Heart Rhythm Society, and the Latin American Society of Cardiac Stimulation and Electrophysiology (Sociedad Latinoamericana de Estimulación Cardíaca y Electrofisiología [SOLAECE]) expert consensus statement on catheter and surgical ablation of AF completely supersedes the 2012 HRS/EHRA/ECAS expert consensus statement. It provides updated definitions, mechanisms, and rationale for AF ablation and consensus recommendations concerning indications, strategies, techniques, and endpoints, technology and tools, and follow-up considerations for AF ablation.

Key points of this document include the following [154] :

  • Catheter and surgical ablation of AF are well established and important treatment options for patients with AF in whom a rhythm control strategy is chosen.
  • Careful consideration of the efficacy, risks, and alternatives to the ablation procedure as well as patient preferences should inform decision making about selection of catheter or surgical ablation of AF. Indications for both catheter and surgical AF ablation are presented.
  • The key indication for AF ablation is the presence of symptoms associated with AF, typically after ineffectiveness or intolerance of at least one antiarrhythmic medication.
  • A desire to stop anticoagulation is not an appropriate indication for AF ablation. For most patients with AF at high risk for stroke, anticoagulation should be continued following the ablation procedure.
  • Catheter ablation of AF is associated with a risk of complications, such as the development of a stroke or transient ischemic attack. Closely monitor anticoagulation before, during, and after the ablation procedure to minimize these risks.
  • Multiple tools and strategies are available to perform both catheter and surgical ablation of AF. The consensus statement provides a detailed review of each of the available options, as well as recommendations.

The 2019 ACC/AHA/HRS focused update on the management of patients with AF indicates that AF catheter ablation may be reasonable in selected patients with symptomatic AF and heart failure (HF) with reduced left ventricular (LV) ejection fraction (HFrEF) to potentially lower the mortality rate and reduce hospitalization for HF. [57]

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Supraventricular Arrhythmias Guidelines

In August 2019, the European Society of Cardiology (ESC) in collaboration with the Association for European Paediatric and Congenital Cardiology (AEPC) released recommendations on the management of supraventricular tachycardia. [155, 156] Previous related guidelines include, but are not limited to, the 2017 European Heart Rhythm Association [157] guidelines for the management of supraventricular tachycardia which includes specific recommendations for both acute and ongoing management of atrial tachycardia. These guidelines are summarized in the following sections.

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2019 ESC/AEPC Guidelines for the Management of Supraventricular Tachycardia

Supraventricular Tachycardia Clinical Practice Guidelines (2019)

Several changes from the previous guidelines (2003) include revised drug grades as well as medications that are no longer considered, and changes to ablation techniques and indications. [155, 156]

Table. Medications, Strategies, and Techniques Specified or Not Mentioned in the 2019 Guidelines (Open Table in a new window)

Type of Tachycardia

Treatment (Grade)

Not Mentioned in 2019 Guidelines

Narrow QRS tachycardias

Verapamil and diltiazem; beta-blockers (now all are grade IIa)

Amiodarone, digoxin

Wide QRS tachycardias

Procainamide, adenosine (both grade IIa); amiodarone (IIb)

Sotalol, lidocaine

Inappropriate sinus tachycardia

Beta-blockers (IIa)

Verapamil/diltiazem, catheter ablation

Postural orthostatic tachycardia syndrome

Salt and fluid intake (IIb)

Head-up tilt sleep, compression stockings, selective beta-blockers, fludrocortisone, clonidine, methylphenidate, fluoxetine, erythropoietin, ergotaminel octreotide, phenobarbitone

Focal atrial tachycardia

Acute: beta-blockers (IIa); flecainide/propafenone, amiodarone (IIb)

Acute: procainamide, sotalol, digoxin

Chronic: beta-blockers; verapamil and diltiazem (all IIa)

Chronic: amiodarone, sotalol, disopyramide

Atrial flutter

Acute: ibutilide (I); verapamil and diltiazem, beta-blockers (all IIa); atrial or transesophageal pacing (IIb); flecainide/propafenone (III)

Acute: digitalis

Chronic:

Chronic: dofetilide, sotalol, flecainide, propafenone, procainamide, quinidine, disopyramide

Atrioventricular nodal re-entrant tachycardia (AVNRT)

Acute:

Acute: amiodarone, sotalol, flecainide, propafenone

Chronic: verapamil and diltiazem; beta-blockers (all IIa)

Chronic: amiodarone, sotalol, flecainide, propafenone, “pill-in-the-pocket” approach

Atrioventricular re-entrant tachycardia (AVRT)

Beta-blockers (IIa); flecainide/propafenone (IIb)

Amiodarone, sotalol, “pill-in-the-pocket” approach

SVT in pregnancy

Verapamil (IIa); catheter ablation (IIa when fluoroless ablation is available)

Sotalol, propafenone, quinidine, procainamide

Adapted from Brugada J, Katritsis DG, Arbelo E, et al, for the ESC Scientific Document Group. 2019 ESC Guidelines for the management of patients with supraventricular tachycardia. The Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J. 2019 Aug 31;ehz467. https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehz467/5556821

2019 New Recommendations

For detailed recommendations on specific types of SVTs, please consult the original guidelines as listed under the references.

Class I (recommended or indicated)

For conversion of atrial flutter: Intravenous (IV) ibutilide, or IV or oral (PO) (in-hospital) dofetilide

For termination of atrial flutter (when an implanted pacemaker or defibrillator is present): High-rate atrial pacing

For asymptomatic patients with high-risk features (eg, shortest pre-excited RR interval during atrial fibrillation [SPERRI] ≤250 ms, accessory pathway [AP] effective refractory period [ERP] ≤250 ms, multiple APs, and an inducible AP-mediated tachycardia) as identified on electrophysiology testing (EPS) using isoprenaline: Catheter ablation

For tachycardia responsible for tachycardiomyopathy that cannot be ablated or controlled by drugs: Atrioventricular nodal ablation followed by pacing (“ablate and pace”) (biventricular or His-bundle pacing)

First trimester of pregnancy: Avoid all antiarrhythmic drugs, if possible

Class IIa (should be considered)

Symptomatic patients with inappropriate sinus tachycardia: Consider ivabradine alone or with a beta-blocker

Atrial flutter without atrial fibrillation: Consider anticoagulation (initiation threshold not yet established)

Asymptomatic preexcitation: Consider EPS for risk stratification

Asymptomatic preexcitation with left ventricular dysfunction due to electrical dyssynchrony: Consider catheter ablation

Class IIb (may be considered)

Acute focal atrial tachycardia: Consider IV ibutilide

Chronic focal atrial tachycardia: Consider ivabradine with a beta-blocker

Postural orthostatic tachycardia syndrome: Consider ivabradine

Asymptomatic preexcitation: Consider noninvasive assessment of the AP conducting properties

Asymptomatic preexcitation with low-risk AP at invasive/noninvasive risk stratification: Consider catheter ablation

Prevention of SVT in pregnant women without Wolff-Parkinson-White syndrome: Consider beta-1 selective blockers (except atenolol) (preferred) or verapamil

Prevention of SVT in pregnant women without Wolff-Parkinson-White syndrome and without ischemic or structural heart disease: Consider flecainide or propafenone

Class III (not recommended)

IV amiodarone is not recommended for preexcited atrial fibrillation.

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2017 EHRA Consensus Document on the Management of Supraventricular Arrhythmias

The European Heart Rhythm Association (EHRA) published its consensus document on the management of supraventricular arrhythmias, which has been endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE). [157]

Acute Management (without established diagnosis)

In the setting of hemodynamically unstable supraventricular tachycardia (SVT), synchronized electrical cardioversion is recommended.

In the setting of hemodynamically stable SVT, vagal maneuvers, preferably in the supine position, or adenosine are recommended. Intravenous (IV) diltiazen or verapamil, or beta blockers, may be considered.

Sinus Tachycardia

Inappropriate sinus tachycardia

  • Therapy is primarily recommended for symptomatic control. Ivabradine is recommended in affected patients.
  • Beta blockers may be considered for second-line therapy, whereas non-dihydropyridine calcium channel blockers may be considered for third-line therapy.
  • Do not routinely consider catheter ablation for patients with inappropriate sinus tachycardia; restrict catheter ablation for the most symptomatic cases following failure of other therapies and measures.

Sinus nodal reentrant tachycardia

  • Catheter ablation may be used in symptomatic patients.
  • Oral beta blockers, diltiazem, or verapamil may be used in symptomatic patients

Focal Atrial Tachycardia

Acute therapy

  • Hemodynamically unstable patients: Synchronized DC cardioversion
  • Terminating a nonreentrant atrial tachycardia or diagnosing the tachycardia mechanism: Adenosine
  • Pharmacologic cardioversion or rate control: IV beta blockers, verapamil, or diltiazem; or IV amiodarone
  • Pharmacologic cardioversion in the absence of structural or ischemic heart disease: IV flecainide or propafenone
  • Pharmacologic cardioversion of microreentrant atrial tachycardia: IV ibutilide

Chronic therapy

  • Catheter ablation, especially for incessant atrial tachycardia
  • Consider beta blockers, verapamil, or diltiazem
  • Consider flecainide or propafenone in the absence of structural or ischemic heart disease

Atrial Flutter (AFL)/ Macroreentrant tachycardia (MRT)

Acute therapy

  • Hemodynamically unstable patients with (AFL/MRT): Synchronized direct current (DC) cardioversion
  • In case emergency cardioversion is necessary: Consider IV anticoagulation; continue anticoagulation for 4 weeks after sinus rhythm is established
  • Acute rate control in hemodynamically stable patients with AFL: IV beta blockers, diltiazem, or verapamil
  • To cardiovert AFL: IV ibutilide or dofetilide (under close monitoring due to proarrhythmic risk)
  • To control ventricular rate: Consider amiodarone
  • To cardiovert AFL/MRT: Consider atrial overdrive pacing (via esophagus or endocardial)
  • To cardiovert AFL in nonurgent situations but only in hospitalized patients (due to a proarrhythmic risk): Oral dofetilide
  • Avoid class Ic antiarrhythmic drugs in the absence of AV blocking agents: There's a risk of slowing the atrial rate and leading to the development of 1:1 atrioventricular (AV) conduction

Chronic therapy

  • Long-term alternative for patients with infrequent AFL recurrences or refusing ablation: One-time or repeated cardiversion associated with antiarrhythmic drugs
  • Patients with recurrent or poorly tolerated typical AFL: Cavotricuspid isthmus ablation
  • Patients with depressed left ventricular (LV) systolic function: Consider ablation to revert dysfunction due to tachycardiomyopathy and to prevent recurrences
  • Early post-atrial fibrillation (AF) ablation (3-6 months) appearance of atypical AFL/MRT: Initial treatment with cardioversion and antiarrhythmic drugs
  • Patients with recurrent atypical or multiple electrocardiographic (ECG) AFL patterns: Consider catheter ablation after the mechanism is documented
  • Consider postablation correction of "AF risk factors" (due to a high incidence of AF after CTI ablation for typical AFL)
  • Patients with AFL episodes: Consider anticoagulation

Stroke prevention

  • Recommended with the same indications as in AF among patients with typical flutter and associated AF episodes
  • Antithrombotic therapy not needed for low-risk AFL patients (ie, CHA 2DS 2-VASc score of 0 in males or 1 in females) (CHA 2DS 2-VASc: ardiac failure, ypertension, ge ≥75 [doubled], iabetes, troke [doubled], ascular disease, ge 65-74, Sex [female])
  • Patients with CHA 2DS 2-VASc ≥1: Oral anticoagulation with either a well-controlled vitamin K antagonist (VKA) with a time in therapeutic range >70%, or with a non-VKA oral anticoagulant (NOAC, either dabigatran, rivaroxaban, apixaban, or edoxaban)
  • Bleeding risk: Assess with HAS-BLED score ( ypertension, bnormal renal/hepatic function, troke, leeding tendency/predisposition, abile international normalized ratio [INR], Age [>65], Drugs [concomitant aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) or alcohol]); identify high-risk patients (score >3) for more frequent review and follow-up, as well as to address reversible bleeding risk factors. A high HAS-BLED score is not a reason to withhold anticoagulation

AV Nodal Reentrant Tachycardia (AVNRT)

Acute therapy

  • Valsalva maneuver, preferably in the supine position, is recommended.
  • IV adenosine is recommended.
  • Hemodynamically unstable patients in whom adenosine fails to terminate the tachycardia: Synchronized DC cardioversion
  • In the absence of hypotension or suspicion of ventricular tachycardia or preexcited AF: IV verapamil or diltiazem
  • Consider IV beta blockers (metoprolol or esmolol); or IV amiodarone; or a single oral dose of diltiazem and propranolol

Chronic therapy

  • Symptomatic patients or patients with an implantable cardioverter-defibrillator: Catheter ablation for slow pathway modification
  • Consider diltiazem or verapamil; or beta blockers
  • Minimally symptomatic patients with infrequent, short-lived tachycardia episode: No therapy

Focal Junctional Tachycardia

In the setting of acute therapy, IV propranolol with or without procainamide, verapamil, or flecainide may be considered.

In the setting of chronic therapy, beta blockers and, in the absence of ischemic or structural heart disease, flecainide or propafenone may be considered. Catheter ablation may be considered, but there is a risk of AV block.

AV Reentrant Tachycardia (AVRT) Due to Manifest/Concealed Accessory Pathways

Acute therapy

  • First-line approach to terminate SVT: Vagal maneuvers (Valsalva and carotid sinus massage), preferably in the supine position
  • To convert to sinus rhythm: Adenosine, but use with caution (it may precipitate AF with a rapid ventricular rate and even ventricular fibrillation)
  • Hemodynamically unstable AVRT patients in whom vagal maneuvers or adenosine are ineffective or not feasible: Synchronized DC shock
  • Patients with antidromic AVRT: Consider IV ibutilide, procainamide, propafenone, or flecainide
  • Patients with orthodromic AVRT: Consider IV beta blockers, diltiazem, or verapamil
  • Patients with preexcited AF: Potentially harmful drugs include IV digoxin, beta blockers, diltiazem, verapamil and, possibly, amiodarone

Chronic therapy

  • Symptomatic patients with AVRT and/or preexcited AF: Catheter ablation of the accessory pathway
  • Symptomatic patients with frequent episodes of AVRT: Consider catheter ablation of the accessory pathway
  • Patients with AVRT and/or preexcited AF, but without structural or ischemic heart disease: Consider oral flecainide or propafenone, preferably in combination with a beta blocker
  • Chronic management of AVRT in the absence of preexcitation sign on resting ECG: Oral beta blockers, diltiazem, or verapamil
  • Oral amiodarone may be considered only among patients in whom other antiarrhythmic drugs are ineffective or contraindicated, and catheter ablation is not an option.

Asymptomatic Preexcitation

Patients with asymptomatic ventricular preexcitation: Consider electrophysiologic (EP) testing for risk stratification.

Asymptomatic patients with preexcited ECG: Consider screening programs for risk stratification.

Catheter ablation of accessory pathways may be considered in asymptomatic patients with accessory pathways with an antegrade refractory period of less than 240 ms, inducible AVRT triggering preexcited AF, and multiple accessory pathways.

Observation without treatment may be reasonable in asymptomatic Wolff-Parkinson-White patients who are considered to be at low risk following an EP study or due to intermittent preexcitation.

SVTs in Patients With Adult Congenital Heart Disease

Acute therapy

Hemodynamically stable SVT (NOTE: Use caution in those with sinus node dysfunction and impaired ventricular function with a need for chronotropic or inotropic support.)

  • Electrical cardioversion
  • Consider IV adenosine for conversion

Hemodynamically stable AVNRT/AVRT

  • Consider IV adenosine
  • Consider atrial overdrive pacing (via esophagus or endocardial)

Hemodynamically stable AFL / atrial tachycardia

  • Consider IV ibutilide for conversion of AFL (Caution: Proarrhythmia may occur in patients with impaired ventricular function.)
  • Consider IV metoprolol (caution for hypotension) for conversion and rate control
  • Consider atrial overdrive pacing for conversion of AFL (via esophagus or endocardial)

Chronic therapy

Recurrent symptomatic SVT

  • Initial evaluation of SVT: Consider hemodynamic evaluation of structural defect for potential repair
  • Consider catheter ablation
  • Recurrent atrial tachycardia or AFL: Consider oral beta blockers
  • Prevention: Consider amiodarone if other drugs and catheter ablation are ineffective or contraindicated
  • Antithrombotic therapy for atrial tachycardia or AFL: Same as for patients with AF
  • Avoid use of oral sotalol (increased risk for proarrhythmias and mortality)
  • Avoid use of flecainide in patients with ventricular dysfunction (increased risk for proarrhythmias and mortality)
  • Atrial-based pacing to decrease recurrence of atrial tachycardia/AFL: It is not recommended that a pacemaker be implanted

Planned surgical repair and symptomatic SVT

  • Consider surgical ablation of atrial tachycardia, AFL, or accessory pathways
  • Patients planned for surgical repair of Ebstein anomaly: Consider preoperative EP study as a routine test
  • Patients with SVT planned for surgical repair of Ebstein anomaly: Consider preoperative catheter ablation, or intraoperative surgical ablation of accessory pathways, AFL, or atrial tachycardia

SVT During Pregnancy

Acute therapy

  • Patients with SVT causing hemodynamic instability: DC cardioversion
  • Vagal maneuvers, preferably in the supine position, may be considered as first-line therapy
  • Adenosine may be considered if vagal maneuvers fail
  • IV metoprolol or propranolol may be considered as a second-line drug if adenosine is ineffective
  • IV verapamil may be considered if adenosine and beta blockers are ineffective or contraindicated

Chronic therapy

  • Patients with tolerable symptoms: Consider no medical therapy
  • Highly symptomatic patients: Consider metoprolol, propranolol, or acebutolol
  • Highly symptomatic patients when beta blockers are ineffective or contraindicated: Verapamil may be reasonable; sotalol and flecainide may be reasonable
  • Highly symptomatic, drug-refractory SVT after the first trimester: Consider catheter ablation
  • Atenolol is not recommended.
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Resources

For more information, please go to Atrial Tachycardia, Atrial Flutter, and Atrioventricular Nodal Reentry Tachycardia.

For more Clinical Practice Guidelines, please go to Guidelines.

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