Guidelines Summary
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.
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. [36, 37]
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.
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). [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.
2015 ACC/AHA/HRS Guideline for the Management of Supraventricular Tachycardia
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]
Resources
For more information, please see the following:
For more Clinical Practice Guidelines, please go to Guidelines.
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Atrial tachycardia. This 12-lead electrocardiogram demonstrates an atrial tachycardia at a rate of approximately 150 beats per minute. Note that the negative P waves in leads III and aVF (upright arrows) are different from the sinus beats (downward arrows). The RP interval exceeds the PR interval during the tachycardia. Note also that the tachycardia persists despite the atrioventricular block.
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Atrial tachycardia. This propagation map of a right atrial tachycardia originating from the right atrial appendage was obtained with non-contact mapping using the EnSite mapping system.
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Atrial tachycardia. Note that the atrial activities originate from the right atrium and persist despite the atrioventricular block. These features essentially exclude atrioventricular nodal reentry tachycardia and atrioventricular tachycardia via an accessory pathway. Note also that the change in the P-wave axis at the onset of tachycardia makes sinus tachycardia unlikely.
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Atrial tachycardia. An anterior-posterior mapping projection is shown. This is an example of activation mapping using contact technique and the EnSite system. The atrial anatomy is partially reconstructed. Early activation points are marked with white/red color. The activation waveform spreads from the inferior/lateral aspect of the atrium through the entire chamber. White points indicate successful ablation sites that terminated the tachycardia. CS = shadow of the catheter inserted in the coronary sinus; TV = tricuspid valve.
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Atrial tachycardia. These intracardiac tracings showing atrial tachycardia breaking with the application of radiofrequency energy. Before ablation, the local electrograms from the treatment site preceded the surface P wave by 51 ms, consistent with this site being the source of the tachycardia. Note that postablation electrograms on the ablation catheter are inscribed well past the onset of the sinus rhythm P wave. The first three tracings show surface electrocardiograms as labeled. Abl = ablation catheter (D-distal pair of electrodes); CS = respective pair of electrodes of the coronary sinus catheter; CS 1,2 = distal pair of electrodes; CS 7,8 = electrodes located at the os of the coronary sinus.
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Atrial tachycardia. This image shows an example of rapid atrial tachycardia mimicking atrial flutter. A single radiofrequency application terminates the tachycardia. The first three tracings show surface electrocardiograms, as labeled. AblD and AblP = distal and proximal pair of electrodes of the mapping catheter, respectively; HBED and HBEP = distal and proximal pair of electrodes in the catheter located at His bundle, respectively; HRA = high right atrial catheter; MAP = unipolar electrograms from the tip of the mapping catheter; RVA = catheter located in right ventricular apex.
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Atrial tachycardia. This electrocardiogram shows multifocal atrial tachycardia (MAT).
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Atrial tachycardia. This electrocardiogram belongs to an asymptomatic 17-year-old male who was incidentally discovered to have Wolff-Parkinson-White (WPW) pattern. It shows sinus rhythm with evident preexcitation. To locate the accessory pathway (AP), the initial 40 milliseconds of the QRS (delta wave) are evaluated. Note that the delta wave is positive in lead I and aVL, negative in III and aVF, isoelectric in V1, and positive in the rest of the precordial leads. Therefore, this is likely a posteroseptal AP.
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Atrial tachycardia. This is a 12-lead electrocardiogram from an asymptomatic 7-year-old boy with Wolff-Parkinson-White (WPW) pattern. Delta waves are positive in leads I and aVL; negative in II, III, and aVF; isoelectric in V1; and positive in the rest of the precordial leads. This again predicts a posteroseptal location for the accessory pathway (AP).