Medication Summary
Drugs used to terminate an acute episode of atrioventricular nodal reentry tachycardia (AVNRT) are given intravenously. These medications include the following:
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Adenosine (first line)
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Calcium channel blockers (eg, diltiazem, verapamil)
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Beta-blockers (eg, esmolol, propranolol, metoprolol, atenolol)
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Digitalis
Drugs used to prevent recurrences are given orally and include calcium channel blockers, long-acting beta-blockers, and digitalis.
As previously mentioned, the administration of adenosine or other AV nodal blocking agents may, in rare cases, lead to ventricular fibrillation or even asystole for a short time period.
Cardiovascular, Other
Class Summary
Antiarrhythmic drugs affect the electrophysiology of the pathways responsible for AVNRT.
Adenosine (Adenocard)
Adenosine transiently blocks conduction through the AV node. It can interrupt reentry pathways through the AV node and restore normal sinus rhythm in paroxysmal SVT, including paroxysmal SVT associated with Wolff-Parkinson-White (WPW) syndrome. Adenosine has a short half-life. It is the preferred medication for IV administration to terminate AVNRT because of its rapid metabolism and generally good safety profile.
Digoxin (Lanoxin)
Cardiac glycosides have direct and indirect inotropic effects on the cardiovascular system. Digoxin acts directly on cardiac muscle, increasing myocardial systolic contractions. Indirect actions result in increased vagal activity for any given increase in mean arterial pressure. Digoxin is administered intravenously to terminate an acute attack, but it has a delayed onset of action and is less effective than other therapies. The drug is given orally to prevent recurrence. IV digoxin has generally been supplanted by other medications.
Calcium Channel Blockers
Class Summary
These drugs block the AV nodal pathways responsible for AVNRT (particularly, the slow pathway).
Diltiazem (Dilacor XR, Tiazac, Cartia XT, Cardizem)
It is administered intravenously to terminate an acute attack, and orally to prevent recurrence.
Verapamil (Calan, Covera-HS, Verelan)
This is the second-line treatment for AVNRT after adenosine. Verapamil causes fewer adverse effects, is less expensive, and lasts longer; however, its action is not as rapid, and hypotension, bradycardia, and a negative inotropic effect may occur. The drug is good to use in lieu of adenosine if AVNRT recurs after termination.
Beta-Blockers, Beta-1 Selective
Class Summary
These agents are used for AV nodal blockade.
Esmolol (Brevibloc)
Esmolol's short half-life of 8 minutes allows for titration to the desired effect and quick discontinuation if necessary.
Atenolol (Tenormin)
Atenolol selectively blocks beta-1 receptors, with little or no effect on beta-2 types. Atenolol is excellent for use in patients at risk for experiencing complications from beta-blockade, particularly those with reactive airway disease, mild-to-moderate LV dysfunction, and/or peripheral vascular disease.
Metoprolol (Lopressor, Toprol XL)
Metoprolol is a selective beta-1 adrenergic receptor blocker that decreases the automaticity of contractions. During intravenous administration, carefully monitor blood pressure, heart rate, and ECG.
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Atrioventricular Nodal Reentry Tachycardia. Electrophysiologic mechanism of atrioventricular nodal reentry tachycardia (AVNRT).
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Atrioventricular Nodal Reentry Tachycardia. Atypical atrioventricular nodal (AV) reentry tachycardia. Often, an inverted P wave is seen just before the QRS complex in leads II, III, aVF. This represents activation of the posterior septum due to antegrade conduction via the fast pathway and retrograde conduction via the slow pathway of the AV node.
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Atrioventricular Nodal Reentry Tachycardia. Typical atrioventricular nodal (AV) reentry tachycardia. In this electrocardiogram, the P wave appears immediately after or just within the QRS complex. Often a “pseudo R wave" is seen in lead V1 and a “pseudo S wave" in leads II, III, aVF. The retrograde P wave represents retrograde activation via the fast pathway, which is anterior septal and superior to the AV node.
Tables
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 |
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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. |
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