Management of Adult Patients With Supraventricular Tachycardia

Publication Date: September 23, 2015

Treatment

Table 2. Acute Treatment of SVT of Unknown Mechanism

Vagal maneuvers are recommended for acute treatment in patients with regular SVT. (I, B-R)
573
Adenosine is recommended for acute treatment in patients with regular SVT. (I, B-R)
573
Synchronized cardioversion is recommended for acute treatment in patients with hemodynamically unstable SVT when vagal maneuvers or adenosine are ineffective or not feasible. (I, B-R)
573
Synchronized cardioversion is recommended for acute treatment in patients with hemodynamically stable SVT when pharmacological therapy is ineffective or contraindicated. (I, B-R)
573
IV diltiazem or verapamil can be effective for acute treatment in patients with hemodynamically stable SVT. (IIa, B-R)
573
IV beta blockers are reasonable for acute treatment in patients with hemodynamically stable SVT. (IIa, C-LD)
573
Colors in tables and figures correspond to Class of Recommendation Table.

Table 3. Ongoing Management of SVT of Unknown Mechanism

Oral beta blockers, diltiazem, or verapamil is useful for ongoing management in patients with symptomatic SVT who do not have ventricular pre-excitation during sinus rhythm. (I, B-R)
573
EP study with the option of ablation is useful for the diagnosis and potential treatment of SVT. (I, B-NR)
573
Patients with SVT should be educated on how to perform vagal maneuvers for ongoing management of SVT. (I, C-LD)
573
Flecainide or propafenone is reasonable for ongoing management in patients without SHD or ischemic heart disease who have symptomatic SVT and are not candidates for, or prefer not to undergo, catheter ablation. (IIa, B-R)
573
Sotalol may be reasonable for ongoing management in patients with symptomatic SVT who are not candidates for, or prefer not to undergo, catheter ablation. (IIb, B-R)
573
Dofetilide may be reasonable for ongoing management in patients with symptomatic SVT who are not candidates for, or prefer not to undergo, catheter ablation and in whom beta blockers, diltiazem, flecainide, propafenone, or verapamil are ineffective or contraindicated. (IIb, B-R)
573
Oral amiodarone may be considered for ongoing management in patients with symptomatic SVT who are not candidates for, or prefer not to undergo, catheter ablation and in whom beta blockers, diltiazem, dofetilide, flecainide, propafenone, sotalol, or verapamil are ineffective or contraindicated. (IIb, C-LD)
573
Oral digoxin may be reasonable for ongoing management in patients with symptomatic SVT without pre-excitation who are not candidates for, or prefer not to undergo, catheter ablation. (IIb, C-LD)
573

ISTa

Table 4. Ongoing Management of IST

Evaluation for and treatment of reversible causes are recommended in patients with suspected IST. (I, C-LD)
573
Ivabradine is reasonable for ongoing management in patients with symptomatic IST. (IIa, B-R)
573
Beta blockers may be considered for ongoing management in patients with symptomatic IST. (IIb, C-LD)
573
The combination of beta blockers and ivabradine may be considered for ongoing management in patients with IST. (IIb, C-LD)
573
There are no specific recommendations for acute treatment of aIST.

Nonsinus Focal AT and MAT

Table 5. Acute Treatment of Suspected Focal AT

IV beta blockers, diltiazem, or verapamil is useful for acute treatment in hemodynamically stable patients with focal AT. (I, C-LD)
573
Synchronized cardioversion is recommended for acute treatment in patients with hemodynamically unstable focal AT. (I, C-LD)
573
Adenosine can be useful in the acute setting to either restore sinus rhythm or diagnose the tachycardia mechanism in patients with suspected focal AT. (IIa, B-NR)
573
IV amiodarone may be reasonable in the acute setting to either restore sinus rhythm or slow the ventricular rate in hemodynamically stable patients with focal AT. (IIb, C-LD)
573
Ibutilide may be reasonable in the acute setting to restore sinus rhythm in hemodynamically stable patients with focal AT. (IIb, C-LD)
573

Table 6. Ongoing Management of Suspected Focal AT

Catheter ablation is recommended in patients with symptomatic focal AT as an alternative to pharmacological therapy. (I, B-NR)
573
Oral beta blockers, diltiazem, or verapamil are reasonable for ongoing management in patients with symptomatic focal AT. (IIa, C-LD)
573
Flecainide or propafenone can be effective for ongoing management in patients without SHD or ischemic heart disease who have focal AT. (IIa, C-LD)
573
Oral sotalol or amiodarone may be reasonable for ongoing management in patients with focal AT. (IIb, C-LD)
573

Table 7. Acute Treatment of MAT

IV metoprolol or verapamil can be useful for acute treatment in patients with MAT. (IIa, C-LD)
573

Table 8. Ongoing Management of MAT

Oral verapamil (IIa, B-NR)
573
or diltiazem (IIa, C-LD)
573
is reasonable for ongoing management in patients with recurrent symptomatic MAT.
Metoprolol is reasonable for ongoing management in patients with recurrent symptomatic MAT. (IIa, C-LD)
573

Table 9. Acute Treatment of AVNRT

Vagal maneuvers are recommended for acute treatment in patients with AVNRT. (I, B-R)
573
Adenosine is recommended for acute treatment in patients with AVNRT. (I, B-R)
573
Synchronized cardioversion should be performed for acute treatment in hemodynamically unstable patients with AVNRT when adenosine and vagal maneuvers do not terminate the tachycardia or are not feasible. (I, B-NR)
573
Synchronized cardioversion is recommended for acute treatment in hemodynamically stable patients with AVNRT when pharmacological therapy does not terminate the tachycardia or is contraindicated. (I, B-NR)
573
IV beta blockers, diltiazem, or verapamil are reasonable for acute treatment in hemodynamically stable patients with AVNRT. (IIa, B-R)
573
Oral beta blockers, diltiazem, or verapamil may be reasonable for acute treatment in hemodynamically stable patients with AVNRT. (IIb, C-LD)
573
IV amiodarone may be considered for acute treatment in hemodynamically stable patients with AVNRT when other therapies are ineffective or contraindicated. (IIb, C-LD)
573

Table 10. Ongoing Management of AVNRT

Oral verapamil or diltiazem is recommended for ongoing management in patients with AVNRT who are not candidates for, or prefer not to undergo, catheter ablation. (I, B-R)
573
Catheter ablation of the slow pathway is recommended in patients with AVNRT. (I, B-NR)
573
Oral beta blockers are recommended for ongoing management in patients with AVNRT who are not candidates for, or prefer not to undergo, catheter ablation. (I, B-R)
573
Flecainide or propafenone is reasonable for ongoing management in patients without SHD or ischemic heart disease who have AVNRT and are not candidates for, or prefer not to undergo, catheter ablation and in whom beta blockers, diltiazem, or verapamil are ineffective or contraindicated. (IIa, B-R)
573
Clinical follow-up without pharmacological therapy or ablation is reasonable for ongoing management in minimally symptomatic patients with AVNRT. (IIa, B-NR)
573
Oral sotalol or dofetilide may be reasonable for ongoing management in patients with AVNRT who are not candidates for, or prefer not to undergo, catheter ablation. (IIb, B-R)
573
Oral digoxin or amiodarone may be reasonable for ongoing treatment of AVNRT in patients who are not candidates for, or prefer not to undergo, catheter ablation. (IIb, B-R)
573
Self-administered (“pill-in-the-pocket”) acute doses of oral beta blockers, diltiazem, or verapamil may be reasonable for ongoing management in patients with infrequent, well-tolerated episodes of AVNRT. (IIb, C-LD)
573

Symptomatic Manifest or Concealed Accessory Pathways

Table 11. Acute Treatment of Orthodromic AVRT

Vagal maneuvers are recommended for acute treatment in patients with orthodromic AVRT. (I, B-R)
573
Adenosine is beneficial for acute treatment in patients with orthodromic AVRT. (I, B-R)
573
Synchronized cardioversion should be performed for acute treatment in hemodynamically unstable patients with AVRT if vagal maneuvers or adenosine are ineffective or not feasible. (I, B-NR)
573
Synchronized cardioversion is recommended for acute treatment in hemodynamically stable patients with AVRT when pharmacological therapy is ineffective or contraindicated. (I, B-NR)
573
Synchronized cardioversion should be performed for acute treatment in hemodynamically unstable patients with pre-excited AF. (I, B-NR)
573
Ibutilide or IV procainamide is beneficial for acute treatment in patients with pre-excited AF who are hemodynamically stable. (I, C-LD)
573
IV diltiazem, verapamil (IIa, B-R)
573
or beta blockers (IIa, C-LD)
573
can be effective for acute treatment in patients with orthodromic AVRT who do not have pre-excitation on their resting ECG during sinus rhythm.
IV beta blockers, diltiazem, and verapamil might be considered for acute treatment in patients with orthodromic AVRT who have pre-excitation on their resting ECG and have not responded to other therapies. (IIb, B-R)
573
IV digoxin, IV amiodarone , IV or oral beta blockers, diltiazem, and verapamil are potentially harmful for acute treatment in patients with pre-excited AF. (III - Harm, C-LD)
573

Table 12. Ongoing Management of Orthodromic AVRT

Catheter ablation of the accessory pathway is recommended in patients with AVRT and/or pre-excited AF. (I, B-NR)
573
Oral beta blockers, diltiazem, or verapamil are indicated for ongoing management of AVRT in patients without pre-excitation on their resting ECG. (I, C-LD)
573
Oral flecainide or propafenone is reasonable for ongoing management in patients without SHD or ischemic heart disease who have AVRT and/or pre-excited AF and are not candidates for, or prefer not to undergo, catheter ablation. (IIa, B-R)
573
Oral dofetilide or sotalol may be reasonable for ongoing management in patients with AVRT and/or pre-excited AF who are not candidates for, or prefer not to undergo, catheter ablation. (IIb, B-R)
573
Oral amiodarone may be considered for ongoing management in patients with AVRT and/or pre-excited AF who are not candidates for, or prefer not to undergo, catheter ablation and in whom beta blockers, diltiazem, flecainide, propafenone, and verapamil are ineffective or contraindicated. (IIb, C-LD)
573
Oral beta blockers, diltiazem, or verapamil may be reasonable for ongoing management of orthodromic AVRT in patients with pre-excitation on their resting ECG who are not candidates for, or prefer not to undergo, catheter ablation. (IIb, C-LD)
573
Oral digoxin may be reasonable for ongoing management of orthodromic AVRT in patients without pre-excitation on their resting ECG who are not candidates for, or prefer not to undergo, catheter ablation. (IIb, C-LD)
573
Oral digoxin is potentially harmful for ongoing management in patients with AVRT or AF and pre-excitation on their resting ECG. (III - Harm, C-LD)
573

Asymptomatic Pre-Excitation

Table 13. Asymptomatic Patients With Pre-Excitation

In asymptomatic patients with pre-excitation, the findings of abrupt loss of conduction over a manifest pathway during exercise testing in sinus rhythm (LOE: B-NR) SR or intermittent loss of pre-excitation during ECG or ambulatory monitoring (LOE: C-LD) SR are useful to identify patients at low risk of rapid conduction over the pathway. (I, B-NR)
SR
573
In asymptomatic patients with pre-excitation, the findings of
abrupt loss of conduction over a manifest pathway during exercise testing in sinus rhythm (I, B-NR)
SR
573
or intermittent loss of pre-excitation during ECG or ambulatory monitoring (I, C-LD)
SR
573
are useful to identify patients at low risk of rapid conduction over the pathway.
An EP study is reasonable in asymptomatic patients with pre-excitation to risk-stratify for arrhythmic events. (IIa, B-NR)
SR
573
Catheter ablation of the accessory pathway is reasonable in asymptomatic patients with pre-excitation if an EP study identifies a high risk of arrhythmic events, including rapidly conducting pre-excited AF. (IIa, B-NR)
SR
573
Catheter ablation of the accessory pathway is reasonable in asymptomatic patients if the presence of pre-excitation precludes specific employment (such as with pilots). (IIa, B-NR)
SR
573
Observation, without further evaluation or treatment, is reasonable in asymptomatic patients with pre-excitation. (IIa, B-NR)
SR
573
a These recommendations have been designated with the notation SR to emphasize the rigor of support from the Evidence Review Committee’s systematic review.

Table 14. Risk Stratification of Symptomatic Patients With Manifest Accessory Pathways

In symptomatic patients with pre-excitation,
the findings of abrupt loss of conduction over the pathway during exercise testing in sinus rhythm (I, B-NR)
573
or intermittent loss of pre-excitation during ECG or ambulatory monitoring (, )
573

are useful to identify patients at low risk of developing rapid conduction over the pathway.

An EP study is useful in symptomatic patients with pre-excitation to risk-stratify for life-threatening arrhythmic events. (I, B-NR)
573

Atrial Flutter

Table 15. Acute Treatment of Atrial Flutter

Oral dofetilide or IV ibutilide is useful for acute pharmacological cardioversion in patients with atrial flutter. (I, A)
573
IV or oral beta blockers, diltiazem, or verapamil are useful for acute rate control in patients with atrial flutter who are hemodynamically stable. (I, B-R)
573
Elective synchronized cardioversion is indicated in stable patients with well-tolerated atrial flutter when a rhythm control strategy is being pursued. (I, B-NR)
573
Synchronized cardioversion is recommended for acute treatment of patients with atrial flutter who are hemodynamically unstable and do not respond to pharmacological therapies. (I, B-NR)
573
Rapid atrial pacing is useful for acute conversion of atrial flutter in patients who have pacing wires in place as part of a permanent pacemaker or implantable cardioverter-defibrillator or for temporary atrial pacing after cardiac surgery. (I, C-LD)
573
Acute antithrombotic therapy is recommended in patients with atrial flutter to align with recommended antithrombotic therapy for patients with AF. (I, B-NR)
573
IV amiodarone can be useful for acute control of the ventricular rate (in the absence of pre-excitation) in patients with atrial flutter and systolic heart failure when beta blockers are contraindicated or ineffective. (IIa, B-R)
573

Table 16. Ongoing Management of Atrial Flutter

Catheter ablation of the CTI is useful in patients with atrial flutter that is either symptomatic or refractory to pharmacological rate control. (I, B-R)
573
Beta blockers, diltiazem, or verapamil are useful to control the ventricular rate in patients with hemodynamically tolerated atrial flutter. (I, C-LD)
573
Catheter ablation is useful in patients with recurrent symptomatic non–CTI-dependent flutter after failure of at least 1 antiarrhythmic agent. (I, C-LD)
573
Ongoing management with antithrombotic therapy is recommended in patients with atrial flutter to align with recommended antithrombotic therapy for patients with AF. (I, B-NR)
573
The following drugs can be useful to maintain sinus rhythm in patients with symptomatic, recurrent atrial flutter, with the drug choice depending on underlying heart disease and comorbidities:
  1. Amiodarone
  2. Dofetilide
  3. Sotalol
(IIa, B-R)
573
Catheter ablation is reasonable in patients with CTI-dependent atrial flutter that occurs as the result of flecainide, propafenone, or amiodarone used for treatment of AF. (IIa, B-NR)
573
Catheter ablation of the CTI is reasonable in patients undergoing catheter ablation of AF who also have a history of documented clinical or induced CTI-dependent atrial flutter. (IIa, C-LD)
573
Catheter ablation is reasonable in patients with recurrent symptomatic non–CTI-dependent flutter as primary therapy, before therapeutic trials of antiarrhythmic drugs, after carefully weighing potential risks and benefits of treatment options. (IIa, C-LD)
573
Flecainide or propafenone may be considered to maintain sinus rhythm in patients without SHD or ischemic heart disease who have symptomatic recurrent atrial flutter. (IIb, B-R)
573
Catheter ablation may be reasonable for asymptomatic patients with recurrent atrial flutter. (IIb, C-LD)
573

Junctional Tachycardia

Table 17. Acute Treatment of Junctional Tachycardia

IV beta blockers are reasonable for acute treatment in patients with symptomatic junctional tachycardia. (IIa, C-LD)
573
IV diltiazem, procainamide, or verapamil is reasonable for acute treatment in patients with junctional tachycardia. (IIa, C-LD)
573

Table 18. Ongoing Management of Junctional Tachycardia

Oral beta blockers are reasonable for ongoing management in patients with junctional tachycardia. (IIa, C-LD)
573
Oral diltiazem or verapamil is reasonable for ongoing management in patients with junctional tachycardia. (IIa, C-LD)
573
Flecainide or propafenone may be reasonable for ongoing management in patients without SHD or ischemic heart disease who have junctional tachycardia. (IIb, C-LD)
573
Catheter ablation may be reasonable in patients with junctional tachycardia when medical therapy is not effective or contraindicated. (IIb, C-LD)
573

ACHD

Table 19. Acute Treatment of ACHD

Acute antithrombotic therapy is recommended in ACHD patients who have AT or atrial flutter to align with recommended antithrombotic therapy for patients with AF. (I, C-LD)
573
Synchronized cardioversion is recommended for acute treatment in ACHD patients and SVT who are hemodynamically unstable. (I, B-NR)
573
IV diltiazem or esmolol (with extra caution using either agent, observing for the development of hypotension) is recommended for acute treatment in ACHD patients and SVT who are hemodynamically stable. (I, C-LD)
573
IV adenosine is recommended for acute treatment in ACHD patients and SVT. (I, B-NR)
573
IV ibutilide or procainamide can be effective for acute treatment in ACHD patients and atrial flutter who are hemodynamically stable. (IIa, B-NR)
573
Atrial pacing can be effective for acute treatment in ACHD patients and SVT who are hemodynamically stable and anticoagulated as per current guidelines for antithrombotic therapy in patients with AF. (IIa, B-NR)
573
Elective synchronized cardioversion can be useful for acute termination of AT or atrial flutter in ACHD patients when acute pharmacological therapy is ineffective or contraindicated. (IIa, B-NR)
573
Oral dofetilide or sotalol may be reasonable for acute treatment in ACHD patients and AT and/or atrial flutter who are hemodynamically stable. (IIb, B-NR)
573

Table 20. Ongoing Management of ACHD

Ongoing management with antithrombotic therapy is recommended in ACHD patients and AT or atrial flutter to align with recommended antithrombotic therapy for patients with AF. (I, C-LD)
573
Assessment of associated hemodynamic abnormalities for potential repair of structural defects is recommended in ACHD patients as part of therapy for SVT. (I, C-LD)
573
Preoperative catheter ablation or intraoperative surgical ablation of accessory pathways or AT is reasonable in patients with SVT who are undergoing surgical repair of Ebstein anomaly. (IIa, B-NR)
573
Oral beta blockers or sotalol therapy can be useful for prevention of recurrent AT or atrial flutter in ACHD patients. (IIa, B-NR)
573
Catheter ablation is reasonable for treatment of recurrent symptomatic SVT in ACHD patients. (IIa, B-NR)
573
Surgical ablation of AT or atrial flutter can be effective in ACHD patients undergoing planned surgical repair. (IIa, B-NR)
573
Atrial pacing may be reasonable to decrease recurrences of AT or atrial flutter in ACHD patients and sinus node dysfunction. (IIb, B-NR)
573
Oral dofetilide may be reasonable for prevention of recurrent AT or atrial flutter in ACHD patients. (IIb, B-NR)
573
Amiodarone may be reasonable for prevention of recurrent AT or atrial flutter in ACHD patients for whom other medications and catheter ablation are ineffective or contraindicated. (IIb, B-NR)
573
Flecainide should not be administered for treatment of SVT in ACHD patients and significant ventricular dysfunction. (III - Harm, B-NR)
573

Table 21. Acute Treatment of SVT in Pregnancy

Vagal maneuvers are recommended for acute treatment in pregnant patients with SVT. (I, C-LD)
573
Adenosine is recommended for acute treatment in pregnant patients with SVT. (I, C-LD)
573
Synchronized cardioversion is recommended for acute treatment in pregnant patients with hemodynamically unstable SVT when pharmacological therapy is ineffective or contraindicated. (I, C-LD)
573
IV metoprolol or propranolol is reasonable for acute treatment in pregnant patients with SVT adenosine is ineffective or contraindicated. (IIa, C-LD)
573
IV verapamil may be reasonable for acute treatment in pregnant patients with SVT when adenosine and beta blockers are ineffective or contraindicated. (IIb, C-LD)
573
IV procainamide may be reasonable for acute treatment in pregnant patients with SVT. (IIb, C-LD)
573
IV amiodarone may be considered for acute treatment in pregnant patients with potentially life-threatening SVT when other therapies are ineffective or contraindicated. (IIb, C-LD)
573

SVT in Pregnancy

Table 22. Ongoing Management of SVT in Pregnancy

The following drugs, alone or in combination, can be effective for ongoing management in pregnant patients with highly symptomatic SVT:
  1. Digoxin
  2. Flecainide
  3. Metoprolol
  4. Propafenone
  5. Propanolol
  6. Sotalol
  7. Verapamil
(IIa, C-LD)
573
Catheter ablation may be reasonable in pregnant patients with highly symptomatic, recurrent, drug-refractory SVT with efforts toward minimizing radiation exposure. (IIb, C-LD)
573
Oral amiodarone may be considered for ongoing management in pregnant patients when treatment of highly symptomatic, recurrent SVT is required and other therapies are ineffective or contraindicated. (IIb, C-LD)
573

SVT in Older Populations

Table 23. Acute Treatment of SVT in Older Populations

Diagnostic and therapeutic approaches to SVT should be individualized in patients more than 75 years of age to incorporate age, comorbid illness, physical and cognitive functions, patient preferences, and severity of symptoms. (I, B-NR)
573

Recommendation Grading

Disclaimer

Overview

Title

Management of Adult Patients With Supraventricular Tachycardia

Authoring Organizations

Publication Month/Year

September 23, 2015

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

He purpose of this joint ACC/AHA/HRS document is to provide a contemporary guideline for the management of adults with all types of SVT other than atrial fibrillation (AF).

Target Patient Population

Adult population (≥18 years of age)

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Management

Diseases/Conditions (MeSH)

D013610 - Tachycardia, D013617 - Tachycardia, Supraventricular

Keywords

supraventricular tachycardia (SVT), Supraventricular Arrhythmias, SVT

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
398
Literature Search Start Date
April 1, 2014
Literature Search End Date
September 30, 2014
Specialties Involved
Cardiology, Family Medicine, Geriatric Medicine, Internal Medicine General, Electrophysiology, Cardiology
Percentage of Authors Reporting COI
100