Key Points
- The writing committee generated a clinical practice guideline that provides for high-quality, evidence-based decision making for patients with SVT.
- The “2015 ACC/AHA/HRS Guideline for the Management of Adult Patients with Supraventricular Tachycardia” replaces the “2003 ACC/AHA/ESC Guidelines for the Management of Patients with Supraventricular Arrhythmias”. It utilizes new knowledge from clinical trials, treatments and drugs, and updates or replaces recommendations.
- Atrial fibrillation is not included in this guideline.
- Shared decision making is stressed in the document with attention to the patient’s preferences and treatment goals and their individual situations.
- The best available evidence indicates that the prevalence of SVT in the general population is 2.29 per 1,000 persons, and the incidence of PSVT is estimated to be 36 per 100,000 persons per year.
- Women have twice the risk of men of developing PSVT. Individuals >65 years of age have >5 times the risk of younger persons of developing PSVT.
- SVT has an impact on quality of life, which varies according to the frequency of episodes, the duration of SVT, and whether symptoms occur not only with exercise but also at rest.
- While drug therapy is largely unchanged from 2003, there is one exception. Ivabradine is a new class of drug that has unique properties for reduction of the heart rate. The guideline provides new recommendations for use of ivabradine for ongoing management in patients with inappropriate sinus tachycardia.
- Ablation techniques have improved, including techniques to minimize radiation exposure. As such, catheter ablation may be reasonable in pregnant patients with highly symptomatic, recurrent, drug-refractory SVT with efforts toward minimizing radiation exposure.
- This guideline also provides new recommendations for the management of patients with asymptomatic WPW pattern, based on a systematic review of the evidence.
General Principles
Table 1. Relevant Terms and Definitions
Arrhythmia/Term and Definition
- Supraventricular tachycardia (SVT)
- An umbrella term used to describe tachycardias (atrial and/or ventricular rates in excess of 100 bpm at rest), the mechanism of which involves tissue from the His bundle or above. These SVTs include IST, AT (including focal and multifocal AT), macroreentrant AT (including typical atrial flutter), junctional tachycardia, AVNRT, and various forms of accessory pathway-mediated reentrant tachycardias. In this guideline, the term does not include AF.
- Paroxysmal supraventricular tachycardia (PSVT)
- A clinical syndrome characterized by the presence of a regular and rapid tachycardia of abrupt onset and termination. These features are characteristic of AVNRT or AVRT, and, less frequently, AT. PSVT represents a subset of SVT.
- Atrial fibrillation (AF)
- A supraventricular arrhythmia with uncoordinated atrial activation and, consequently, ineffective atrial contraction. ECG characteristics include: 1) irregular atrial activity, 2) absence of distinct P waves, and 3) irregular R-R intervals (when AV conduction is present). AF is not addressed in this document.
- Sinus tachycardia
- Rhythm arising from the sinus node in which the rate of impulses exceeds 100 bpm.
- Physiologic sinus tachycardia
- Appropriate increased sinus rate in response to exercise and other situations that increase sympathetic tone.
- Inappropriate sinus tachycardia (IST)
- Sinus heart rate >100 bpm at rest, with a mean 24-h heart rate >90 bpm not due to appropriate physiological responses or primary causes such as hyperthyroidism or anemia.
- Physiologic sinus tachycardia
- Rhythm arising from the sinus node in which the rate of impulses exceeds 100 bpm.
- Atrial tachycardia (AT)
- Focal AT
- An SVT arising from a localized atrial site, characterized by regular, organized atrial activity with discrete P waves and typically an isoelectric segment between P waves. At times, irregularity is seen, especially at onset (“warm-up”) and termination (“warm-down”). Atrial mapping reveals a focal point of origin.
- Sinus node reentry tachycardia
- A specific type of focal AT that is due to microreentry arising from the sinus node complex, characterized by abrupt onset and termination, resulting in a P-wave morphology that is indistinguishable from sinus rhythm.
- Multifocal atrial tachycardia (MAT)
- An irregular SVT characterized by ≥3 distinct P-wave morphologies and/or patterns of atrial activation at different rates. The rhythm is always irregular.
- Focal AT
- Atrial flutter
- Cavotricuspid isthmus (CTI)– dependent atrial flutter: typical
- Macroreentrant AT propagating around the tricuspid annulus, proceeding superiorly along the atrial septum, inferiorly along the right atrial wall, and through the CTI between the tricuspid valve annulus and the Eustachian valve and ridge. This activation sequence produces predominantly negative "sawtooth" flutter waves on the ECG in leads 2, 3, and aVF and a late positive deflection in V1. The atrial rate can be slower than the typical 300 bpm (cycle length 200 ms) in the presence of antiarrhythmic drugs or scarring. It is also known as "typical atrial flutter" or "CTI– dependent atrial flutter" or "counterclockwise atrial flutter."
- CTI– dependent atrial flutter: reverse typical
- Macroreentrant AT that propagates around in the direction reverse that of typical atrial flutter. Flutter waves typically appear positive in the inferior leads and negative in V1. This type of atrial flutter is also referred to as "reverse typical" atrial flutter or "clockwise typical atrial flutter.”
- Atypical or non- CTI– dependent atrial flutter
- Macroreentrant ATs that do not involve the CTI. A variety of reentrant circuits may include reentry around the mitral valve annulus or scar tissue within the left or right atrium. A variety of terms have been applied to these arrhythmias according to the reentry circuit location, including particular forms, such as "LA flutter" and “LA macroreentrant tachycardia" or incisional atrial reentrant tachycardia due to reentry around surgical scars.
- Cavotricuspid isthmus (CTI)– dependent atrial flutter: typical
- Junctional tachycardia
- A nonreentrant SVT that arises from the AV junction (including the His bundle).
- Atrioventricular nodal reentrant tachycardia (AVNRT)
- A reentrant tachycardia involving 2 functionally distinct pathways, generally referred to as "fast" and "slow" pathways. Most commonly, the fast pathway is located near the apex of Koch’s triangle, and the slow pathway inferoposterior to the compact AV node tissue. Variant pathways have been described, allowing for “slow-slow” AVNRT.
- Typical AVNRT
- AVNRT in which a slow pathway serves as the anterograde limb of the circuit and the fast pathway serves as the retrograde limb (also called “slow-fast AVNRT”).
- Atypical AVNRT
- AVNRT in which the fast pathway serves as the anterograde limb of the circuit and a slow pathway serves as the retrograde limb (also called “fast-slow AV node reentry”) or a slow pathway serves as the anterograde limb and a second slow pathway serves as the retrograde limb (also called “slow-slow AVNRT”).
- Typical AVNRT
- A reentrant tachycardia involving 2 functionally distinct pathways, generally referred to as "fast" and "slow" pathways. Most commonly, the fast pathway is located near the apex of Koch’s triangle, and the slow pathway inferoposterior to the compact AV node tissue. Variant pathways have been described, allowing for “slow-slow” AVNRT.
- Accessory pathway
- For the purpose of this guideline, an accessory pathway is defined as an extranodal AV pathway that connects the myocardium of the atrium to the ventricle across the AV groove. Accessory pathways can be classified by their location, type of conduction (decremental or nondecremental), and whether they are capable of conducting anterogradely, retrogradely, or in both directions. Of note, accessory pathways of other types (such as atriofascicular, nodo-fascicular, nodo-ventricular, and fasciculoventricular pathways) are uncommon.
- Manifest accessory pathways
- A pathway that conducts anterogradely to cause ventricular pre-excitation pattern on the ECG.
- Concealed accessory pathway
- A pathway that conducts only retrogradely and does not affect the ECG pattern during sinus rhythm.
- Pre-excitation pattern
- An ECG pattern reflecting the presence of a manifest accessory pathway connecting the atrium to the ventricle. Pre-excited ventricular activation over the accessory pathway competes with the anterograde conduction over the AV node and spreads from the accessory pathway insertion point in the ventricular myocardium. Depending on the relative contribution from ventricular activation by the normal AV nodal / His Purkinje system versus the manifest accessory pathway, a variable degree of pre-excitation, with its characteristic pattern of a short P-R interval with slurring of the initial upstroke of the QRS complex (delta wave), is observed. Pre-excitation can be intermittent or not easily appreciated for some pathways capable of anterograde conduction; this is usually associated with a low-risk pathway, but exceptions occur.
- Asymptomatic pre- excitation (isolated pre-excitation)
- The abnormal pre-excitation ECG pattern in the absence of documented SVT or symptoms consistent with SVT.
- Wolff-Parkinson-White (WPW) syndrome
- Syndrome characterized by documented SVT or symptoms consistent with SVT in a patient with ventricular pre-excitation during sinus rhythm.
- Manifest accessory pathways
- For the purpose of this guideline, an accessory pathway is defined as an extranodal AV pathway that connects the myocardium of the atrium to the ventricle across the AV groove. Accessory pathways can be classified by their location, type of conduction (decremental or nondecremental), and whether they are capable of conducting anterogradely, retrogradely, or in both directions. Of note, accessory pathways of other types (such as atriofascicular, nodo-fascicular, nodo-ventricular, and fasciculoventricular pathways) are uncommon.
- Atrioventricular reentrant tachycardia (AVRT)
- A reentrant tachycardia, the electrical pathway of which requires an accessory pathway, the atrium, AV node (or second accessory pathway), and ventricle.
- Orthodromic AVRT
- An AVRT in which the reentrant impulse uses the accessory pathway in the retrograde direction from the ventricle to the atrium, and the AV node in the anterograde direction. The QRS complex is generally narrow or may be wide because of pre-existing bundle-branch block or aberrant conduction.
- Antidromic AVRT
- An AVRT in which the reentrant impulse uses the accessory pathway in the anterograde direction from the atrium to the ventricle, and the AV node for the retrograde direction. Occasionally, instead of the AV node, another accessory pathway can be used in the retrograde direction, which is referred to as pre-excited AVRT. The QRS complex is wide (maximally pre-excited).
- Orthodromic AVRT
- A reentrant tachycardia, the electrical pathway of which requires an accessory pathway, the atrium, AV node (or second accessory pathway), and ventricle.
- Permanent form of junctional reciprocating tachycardia (PJRT)
- A rare form of nearly incessant orthodromic AVRT involving a slowly conducting, concealed, usually posteroseptal accessory pathway.
- Pre-excited AF
- AF with ventricular pre-excitation caused by conduction over ≥1 accessory pathway(s).
Diagnosis
Figure 1. Differential Diagnosis for Adult Narrow QRS Tachycardia
