2019 ESC/AEPC Guidelines for the Management of Supraventricular Tachycardia
The recommendations on the management of supraventricular tachycardia (SVT) were released in August 2019 by the European Society of Cardiology (ESC) in collaboration with the Association for European Paediatric and Congenital Cardiology (AEPC). [24, 58] 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.
Recommendations for management of AVNRT
Acute management
For hemodynamically unstable patients, synchronized direct current (DC) cardioversion is recommended (class I: recommended or indicated)
For hemodynamically stable patients, note the following class I recommendations:
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Vagal maneuvers; the supine position with leg elevation is preferred
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If vagal maneuvers fail, administer adenosine (6-18 mg intravenous [IV] bolus)
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Synchronized DC cardioversion in the setting of failed drug therapy to convert or control the tachycardia
For hemodynamically stable patients, the following are class IIa (should be considered) recommendations:
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If vagal maneuvers and adenosine fail, consider IV verapamil or diltiazem, or consider beta-blockers (IV esmolol or metoprolol)
Chronic management
Catheter ablation is recommended for symptomatic, recurrent AVNRT (class I).
If ablation is not desirable or feasible, consider diltiazem or verapamil, in patients without heart failure with reduced ejection fraction (HFrEF), or beta-blockers (class IIa).
Consider abstinence from therapy for minimally symptomatic patients with very infrequent, short-lived episodes of tachycardia (class IIa).
2019 New Recommendations
For detailed recommendations on specific types of SVTs, please consult the original guidelines. [24]
Class I (recommended or indicated)
For conversion of atrial flutter: 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 with 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.
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 reentrant 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 reentrant 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 | ||
2015 ACC/AHA/HRS Guidelines for the Management of Supraventricular Tachycardia
In 2015, the American College of Cardiology, American Heart Association, and the Heart Rhythm Society (ACC/AHA/HRS) released joint guidelines for the management of supraventricular tachycardia that includes specific recommendations for both acute and ongoing ;management of atrioventricular node reentry tachycardia (AVNRT). [25]
Management of Acute AVNRT
Vagal maneuvers and/or 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
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Synchronized cardioversion (class I; level of evidence B-NR)
Hemodynamically stable patients
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Synchronized cardioversion when beta blockers, diltiazem, or verapamil are ineffective or contraindicated (class I; level of evidence B-NR)
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IV beta blockers, diltiazem, or verapamil (class IIa; level of evidence: B-R)
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Oral beta blockers, diltiazem, or verapamil may be considered (class IIb; level of evidence: C-LD)
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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 terminate 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 may be reasonable for patients with infrequent, well-tolerated episodes of AVNRT. (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 for, or prefer not to undergo, catheter ablation should be treated with verapamil, diltiazem, or oral beta blockers. (Class I; level of evidence B-R)
Additional treatment options for ongoing treatment of AVNRT include:
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Flecainide or propafenone in patients without structural heart disease or ischemic heart disease when Class I therapies (catheter ablation; beta blockers, diltiazem, or verapamil) are ineffective or contraindicated. (Class IIa; level of evidence B-R)
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Oral sotalol, dofetilide, oral digoxin, or amiodarone may be reasonable for patients who are not candidates for, or prefer not to, undergo catheter ablation. (Class IIb; level of evidence B-R)
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Atrioventricular Node Reentry Supraventricular Tachycardia. Nonsustained atrioventricular node reentry tachycardia (AVNRT). This electrocardiogram is from a 10-year-old who is in sinus rhythm until a junction escape beat initiates a 5-beat run of supraventricular tachycardia. The heart rate is quite slow at 130 beats per minute, likely due to his resting state (higher vagal tone) and treatment with the beta-blocker atenolol. Note the pseudo R' waves in lead V1. These deflections represent retrograde atrial activation. Some patients may also exhibit pseudo S waves in the inferior leads. The R' waves are lost when the tachycardia ends, demonstrating that the R' wave is not associated with ventricular depolarization. The terminal QRS has no R' wave, indicating that the tachycardia terminated in the retrograde limb of the circuit (fast AV nodal pathway).
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Atrioventricular Node Reentry Supraventricular Tachycardia. Low voltage bridge in atrioventricular node reentry tachycardia (AVNRT). The images are a three-dimensional electroanatomic voltage map of the right atrium in the left anterior oblique projection with caudal angulation. The purple regions represent areas of high ("normal") atrial electrogram voltage, whereas gray and red regions have lower amplitude signals. The red region projecting from the tricuspid annulus (cutout) posteriorly toward the coronary sinus (thin purple cylinder) is a potential target for slow pathway ablation. The white spherical images are locations where cryotherapy of lesions were performed. The lesion highlighted in yellow represents the location of the successful slow pathway ablation. The others are "insurance" lesions.
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 |
| 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 reentrant 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 reentrant 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 | ||
