Atrioventricular Nodal Reentry Tachycardia Guidelines

Updated: Nov 19, 2019
  • Author: Brian Olshansky, MD, FESC, FAHA, FACC, FHRS; Chief Editor: Jose M Dizon, MD  more...
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Guidelines

Guidelines Summary

In 2015, American College of Cardiology, American Heart Association, Heart Rhythm Society (ACC/AHA/HRS) [15] released guidelines for the management of supraventricular tachycardia which include specific recommendations for both acute and ongoing management of atrioventricular node reentry tachycardia (AVNRT). 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. [16, 17] The European Heart Rhythm Association (EHRA) released recommendations in 2017. [18] These guidelines are summarized in the following sections.

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2015 ACC/AHA/HRS guidelines for the management of supraventricular tachycardia (SVT)

Management of Acute Atrioventricular (AV) Nodal Reentry Tachycardia (AVNRT)

Vagal maneuvers and/or intravenous (IV) adenosine are the recommended initial treatments for acute AVNRT. (Class I; level of evidence B-R)

Additional recommendations for acute treatment when adenosine and vagal maneuvers are ineffective or contraindicated are summarized below.

Hemodynamically unstable patients

  • Synchronized cardioversion (Class I; level of evidence B-NR)

Hemodynamically stable patients

  • IV beta blockers, diltiazem, or verapamil (Class IIa; level of evidence: B-R)
  • Oral beta blockers, diltiazem, or verapamil may be considered. (Class IIb; level of evidence: C-LD)
  • Synchronized cardioversion when beta blockers, diltiazem, or verapamil are ineffective or contraindicated (Class I; level of evidence B-NR)
  • IV amiodarone may be considered when other therapies are ineffective or contraindicated. (Class IIb; Level of evidence: C-LD)

The guidelines note that for rhythms that break or recur spontaneously, synchronized cardioversion is not appropriate.

Management of Ongoing AVNRT

Minimally symptomatic

Clinical follow-up without pharmacologic therapy or ablation is reasonable for minimally symptomatic patients with AVNRT. (Class IIa; level of evidence B-R)

Self-administered (“pill-in-the-pocket”) acute doses of oral beta blockers, diltiazem, or verapamil for patients with infrequent, well-tolerated episodes of AVNRT may be considered. (Class IIb; level of evidence C-LD)

Symptomatic

Catheter ablation of the slow pathway is the recommended initial treatment for ongoing management of symptomatic AVNRT. (Class I; level of evidence B-R).

Patients who are not candidates or prefer not to undergo catheter ablation should be treated with oral beta blockers, verapamil, or diltiazem (Class I; level of evidence B-R). If these agents are ineffective, additional treatment options include:

  • ​Flecainide or propafenone in patients without structural heart disease or ischemic heart disease when class I therapies are ineffective or contraindicated. (Class IIa; level of evidence B-R)
  • Oral sotalol, dofetilide, digoxin, or amiodarone for patients (Class IIb; level of evidence B-R)
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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. [16, 17] For detailed recommendations on specific types of SVTs, please consult the original guidelines as listed under the references.

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

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

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

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

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.

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

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.

SVTs in Patients With Adult Congenital Heart Disease

For acute therapy for patients with hemodynamically stable AVNRT/AVRT, IV adenosine and atrial overdrive pacing (via esophagus or endocardial) may be considered.

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