Atrial Tachycardia 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. ^{[36, 37]}  Previous related guidelines include, but are not limited to, the 2015 American College of Cardiology, American Heart Association, and Heart Rhythm Society (ACC/AHA/HRS) ^[35] and 2017 European Heart Rhythm Association ^[38] guidelines for the management of supraventricular tachycardia include specific recommendations for both acute and ongoing management of atrial tachycardia. These guidelines are summarized in the following sections.

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. ^{[36, 37]}

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

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.

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). ^[38]

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: C ardiac failure, H ypertension, A ge ≥75 [doubled], D iabetes, S troke [doubled], V ascular disease, A 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 ( H ypertension, A bnormal renal/hepatic function,  S troke, B leeding tendency/predisposition, L 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.

Acute atrial tachycardia

Recommendations for acute treatment are summarized below. ^[35]

Hemodynamically unstable patients

• Intravenous (IV) adenosine (class IIa; level of evidence [LOE]: C-LD)
• Synchronized cardioversion, if IV adenosine is ineffective or not feasible (class I; LOE: C-LD)

Hemodynamically stable patients

• IV beta blockers, diltiazem, or verapamil (class I; LOE: C-LD)
• IV adenosine, if the diagnosis is suspected but not established (class IIa; LOE: B-NR)
• IV amiodarone or ibutilide, if beta blockers, diltiazem, verapamil, or adenosine are ineffective (class IIb; LOE: C-LD)

Ongoing atrial tachycardia

Catheter ablation is preferred treatment. (Class I; LOE: B-NR)

Other therapeutic options include the following:

• Oral beta blockers, diltiazem, or verapamil (class IIa; LOE: C-LD)
• Flecainide or propafenone in patients without structural heart disease or ischemic heart disease (class IIa; LOE: C-LD)
• Oral sotalol or amiodarone (class IIb; LOE: C-LD)

Multifocal atrial tachycardia (MAT)

The guidelines emphasize that the first-line treatment is management of the underlying condition. Cardioversion and antiarrhythmic medications were not found to be helpful in suppression of MAT.

For acute treatment in patients with MAT, IV metoprolol or verapamil were recommended; for ongoing management of recurrent symptomatic MAT, oral verapamil (class IIa; LOE: B-NR), metoprolol, or diltiazem may be used. (All class IIa; LOE: C-LD) ^[35]

For more information, please see the following:

• 2019 ESC/AEPC Guidelines for the Management of Supraventricular Tachycardia
• 2017 EHRA Consensus Document on the Management of Supraventricular Arrhythmias
• 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia

For more Clinical Practice Guidelines, please go to Guidelines.