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* Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.
* Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.
* Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. † HRS Representative.
* Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.
§ ACC/AHA Task Force on Performance Measures Liaison.
Jamie B. Conti
Footnotes
* Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. ‡ ACC/AHA Representative. § ACC/AHA Task Force on Performance Measures Liaison.
* Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.
* Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. ‡ ACC/AHA Representative.
* Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.
* Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. † HRS Representative.
* Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.
* Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. ‡ ACC/AHA Representative.
* Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.
§ ACC/AHA Task Force on Performance Measures Liaison.
Andrea M. Russo
Footnotes
* Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. § ACC/AHA Task Force on Performance Measures Liaison.
* Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. † HRS Representative. ‡ ACC/AHA Representative. § ACC/AHA Task Force on Performance Measures Liaison. ‖ ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶ Former Task Force member; current member during this writing effort.
Former Task Force member; current member during this writing effort.
Duminda N. Wijeysundera, MD, PhD
PREAMBLE
Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, based on systematic methods to evaluate and classify evidence, provide a cornerstone of quality cardiovascular care.
In response to reports from the Institute of Medicine
Committee on Standards for Developing Trustworthy Clinical Practice Guidelines, Institute of Medicine (U.S.) Clinical Practice Guidelines We Can Trust.
Committee on Standards for Systematic Reviews of Comparative Effectiveness Research, Institute of Medicine (U.S.) Finding What Works in Health Care: Standards for Systematic Reviews.
and a mandate to evaluate new knowledge and maintain relevance at the point of care, the ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) modified its methodology.
ACCF/AHA clinical practice guideline methodology summit report: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
The evolution and future of ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
ACCF/AHA clinical practice guideline methodology summit report: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
Practice guidelines provide recommendations applicable to patients with or at risk of developing cardiovascular disease. The focus is on medical practice in the United States, but guidelines developed in collaboration with other organizations may have a broader target. Although guidelines may inform regulatory or payer decisions, they are intended to improve quality of care in the interest of patients.
Evidence Review
Guideline Writing Committee (GWC) members review the literature; weigh the quality of evidence for or against particular tests, treatments, or procedures; and estimate expected health outcomes. In developing recommendations, the GWC uses evidence-based methodologies that are based on all available data.
ACCF/AHA clinical practice guideline methodology summit report: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
The evolution and future of ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines.
Literature searches focus on randomized controlled trials (RCTs) but also include registries, nonrandomized comparative and descriptive studies, case series, cohort studies, systematic reviews, and expert opinion. Only selected references are cited.
The Task Force recognizes the need for objective, independent Evidence Review Committees (ERCs) that include methodologists, epidemiologists, clinicians, and biostatisticians who systematically survey, abstract, and assess the evidence to address key clinical questions posed in the PICOTS format (P=population, I=intervention, C=comparator, O=outcome, T=timing, S=setting).
ACCF/AHA clinical practice guideline methodology summit report: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
The evolution and future of ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
Practical considerations, including time and resource constraints, limit the ERCs to evidence that is relevant to key clinical questions and lends itself to systematic review and analysis that could affect the strength of corresponding recommendations. Recommendations developed by the GWC on the basis of the systematic review are marked “SR”.
Guideline-Directed Medical Therapy
The term “guideline-directed medical therapy” refers to care defined mainly by ACC/AHA Class I recommendations. For these and all recommended drug treatment regimens, the reader should confirm dosage with product insert material and carefully evaluate for contraindications and interactions. Recommendations are limited to treatments, drugs, and devices approved for clinical use in the United States.
Class of Recommendation and Level of Evidence
The Class of Recommendation (COR; i.e., the strength of the recommendation) encompasses the anticipated magnitude and certainty of benefit in proportion to risk. The Level of Evidence (LOE) rates evidence supporting the effect of the intervention on the basis of the type, quality, quantity, and consistency of data from clinical trials and other reports (Table 1. )
The evolution and future of ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
Further evolution of the ACC/AHA clinical practice guideline recommendation classification system: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Practice Guidelines.
J Am Coll Cardiol.2015; (In press. http://dx.doi.org/10.1016/j.jacc.2015.09.001)
Unless otherwise stated, recommendations are sequenced by COR and then by LOE. Where comparative data exist, preferred strategies take precedence. When >1 drug, strategy, or therapy exists within the same COR and LOE and no comparative data are available, options are listed alphabetically. Each recommendation is followed by supplemental text linked to supporting references and evidence tables.
Table 1Applying class of recommendation and level of evidence to clinical strategies, interventions, treatments, or diagnostic testing in patient care*
The ACC and AHA sponsor the guidelines without commercial support, and members volunteer their time. The Task Force zealously avoids actual, potential, or perceived conflicts of interest that might arise through relationships with industry or other entities (RWI). All GWC members and reviewers are required to disclose current industry relationships or personal interests from 12 months before initiation of the writing effort. Management of RWI involves selecting a balanced GWC and assuring that the chair and a majority of committee members have no relevant RWI (Appendix 1). Members are restricted with regard to writing or voting on sections to which their RWI apply. For transparency, members’ comprehensive disclosure information is available online. Comprehensive disclosure information for the Task Force is also available online. The Task Force strives to avoid bias by selecting experts from a broad array of backgrounds representing different geographic regions, sexes, ethnicities, intellectual perspectives/biases, and scopes of clinical practice, and by inviting organizations and professional societies with related interests and expertise to participate as partners or collaborators.
Individualizing Care in Patients With Associated Conditions and Comorbidities
Managing patients with multiple conditions can be complex, especially when recommendations applicable to coexisting illnesses are discordant or interacting.
AHA/ACC/HHS strategies to enhance application of clinical practice guidelines in patients with cardiovascular disease and comorbid conditions: from the American Heart Association, American College of Cardiology, and U.S. Department of Health and Human Services.
The guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances. The recommendations should not replace clinical judgment.
Clinical Implementation
Management in accordance with guideline recommendations is effective only when followed. Adherence to recommendations can be enhanced by shared decision making between clinicians and patients, with patient engagement in selecting interventions based on individual values, preferences, and associated conditions and comorbidities. Consequently, circumstances may arise in which deviations from these guidelines are appropriate.
Policy
The recommendations in this guideline represent the official policy of the ACC and AHA until superseded by published addenda, statements of clarification, focused updates, or revised full-text guidelines. To ensure that guidelines remain current, new data are reviewed biannually to determine whether recommendations should be modified. In general, full revisions are posted in 5-year cycles.
The evolution and future of ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.
J Am Coll Cardiol.2015; (In press. http://dx.doi.org/10.1016/j.jacc.2015.09.019)
for additional guidance and details with regard to SVT because the executive summary contains limited information.
Jonathan L. Halperin, MD, FACC, FAHA
Chair, ACC/AHA Task Force on Clinical Practice Guidelines
1. Introduction
1.1 Methodology and Evidence Review
The recommendations listed in this guideline are, whenever possible, evidence based. An extensive evidence review was conducted in April 2014 that included literature published through September 2014. Other selected references published through May 2015 were incorporated by the GWC. Literature included was derived from research involving human subjects, published in English, and indexed in MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. The relevant search terms and data are included in evidence tables in the Online Data Supplement. Additionally, the GWC reviewed documents related to supraventricular tachycardia (SVT) previously published by the ACC, AHA, and Heart Rhythm Society (HRS). References selected and published in this document are representative and not all-inclusive.
An independent ERC was commissioned to perform a systematic review of key clinical questions, the results of which were considered by the GWC for incorporation into this guideline. The systematic review report on the management of asymptomatic patients with Wolff-Parkinson-White (WPW) syndrome is published in conjunction with this guideline.
Risk stratification for arrhythmic events in patients with asymptomatic pre-excitation: a systematic review for the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.
J Am Coll Cardiol.2015; (In press. http://dx.doi.org/10.1016/j.jacc.2015.09.018)
The GWC consisted of clinicians, cardiologists, electrophysiologists (including those specialized in pediatrics), and a nurse (in the role of patient representative) and included representatives from the ACC, AHA, and HRS.
1.3 Document Review and Approval
This document was reviewed by 8 official reviewers nominated by the ACC, AHA, and HRS, and 25 individual content reviewers. Reviewers’ RWI information was distributed to the GWC and is published in this document (Appendix 2).
This document was approved for publication by the governing bodies of the ACC, the AHA, and the HRS.
1.4 Scope of the Guideline
The 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). Although AF is, strictly speaking, an SVT, the term SVT generally does not refer to AF. AF is addressed in the 2014 ACC/AHA/HRS Guideline for the Management of Atrial Fibrillation (2014 AF guideline).
2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
The present guideline addresses other SVTs, including regular narrow–QRS complex tachycardias, as well as other, irregular SVTs (e.g., atrial flutter with irregular ventricular response and multifocal atrial tachycardia [MAT]). This guideline supersedes the “2003 ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias”.
ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias–executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias). Developed in collaboration with NASPE-Heart Rhythm Society.
Although this document is aimed at the adult population (≥18 years of age) and offers no specific recommendations for pediatric patients, as per the reference list, we examined literature that included pediatric patients. In some cases, the data from noninfant pediatric patients helped inform this guideline.
2. General Principles
2.1 Mechanisms and Definitions
For the purposes of this guideline, SVT is defined as per Table 2, which provides definitions and the mechanism(s) of each type of SVT. The term SVT does not generally include AF, and this document does not discuss the management of AF.
Table 2Relevant Terms and Definitions
Arrhythmia/Term
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 inappropriate sinus tachycardia, 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 atrioventricular 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
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.
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.
Macroreentrant AT propagating around the tricuspid annulus, proceeding superiorly along the atrial septum, inferiorly along the right atrial wall, and through the cavotricuspid isthmus 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 “cavotricuspid isthmus–dependent atrial flutter” or “counterclockwise atrial flutter.”
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–cavotricuspid isthmus–dependent atrial flutter
Macroreentrant ATs that do not involve the cavotricuspid isthmus. 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.
Junctional tachycardia
A nonreentrant SVT that arises from the AV junction (including the His bundle).
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”).
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 and are discussed only briefly in this document (Section 7).
•
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.
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.
Atrioventricular reentrant tachycardia (AVRT)
A reentrant tachycardia, the electrical pathway of which requires an accessory pathway, the atrium, atrioventricular 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).
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).
AF indicates atrial fibrillation; AT, atrial tachycardia; AV, atrioventricular; AVNRT, atrioventricular nodal reentrant tachycardia; AVRT, atrioventricular reentrant tachycardia; bpm, beats per minute; ECG, electrocardiogram/electrocardiographic; LA, left atrial; MAT, multifocal atrial tachycardia; PJRT, permanent form of junctional reciprocating tachycardia; PSVT, paroxysmal supraventricular tachycardia; SVT, supraventricular tachycardia; and WPW, Wolff-Parkinson-White.
When adjusted by age and sex in the U.S. population, the incidence of paroxysmal supraventricular tachycardia (PSVT) is estimated to be 36 per 100,000 persons per year.
Compared with patients with cardiovascular disease, those with PSVT without any cardiovascular disease are younger (37 versus 69 years; p = 0.0002) and have faster PSVT (186 versus 155 bpm; p = 0.0006). Women have twice the risk of men of developing PSVT.
Atrioventricular nodal reentrant tachycardia (AVNRT) is more common in persons who are middle-aged or older, whereas in adolescents the prevalence may be more balanced between atrioventricular reentrant tachycardia (AVRT) and AVNRT, or AVRT may be more prevalent.
The relative frequency of tachycardia mediated by an accessory pathway decreases with age. The incidence of manifest pre-excitation or WPW pattern on electrocardiogram/electrocardiographic (ECG) tracings in the general population is 0.1% to 0.3%. However, not all patients with manifest ventricular pre-excitation develop PSVT.
Epidemiological profile of Wolff-Parkinson-White syndrome in a general population younger than 50 years of age in an era of radiofrequency catheter ablation.
2.3 Evaluation of the Patient With Suspected or Documented SVT
2.3.1 Clinical Presentation and Differential Diagnosis on the Basis of Symptoms
The diagnosis of SVT is often made in the emergency department, but it is common to elicit symptoms suggestive of SVT before initial electrocardiographic documentation. SVT symptom onset often begins in adulthood; in one study in adults, the mean age of symptom onset was 32 ± 18 years of age for AVNRT, versus 23 ± 14 years of age for AVRT.
Does atrioventricular reentry tachycardia (AVRT) or atrioventricular nodal reentry tachycardia (AVNRT) in children affect their cognitive and emotional development?.
Combined evaluation of bedside clinical variables and the electrocardiogram for the differential diagnosis of paroxysmal atrioventricular reciprocating tachycardias in patients without pre-excitation.
Gender and atrioventricular conduction properties of patients with symptomatic atrioventricular nodal reentrant tachycardia and Wolff-Parkinson-White syndrome.
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.
Does atrioventricular reentry tachycardia (AVRT) or atrioventricular nodal reentry tachycardia (AVNRT) in children affect their cognitive and emotional development?.
Wolff-Parkinson-White syndrome and atrioventricular nodal re-entry tachycardia in a Swedish population: consequences on health-related quality of life.
In 1 retrospective study in which the records of patients <21 years of age with WPW pattern on the ECG were reviewed, 64% of patients had symptoms at presentation, and an additional 20% developed symptoms during follow-up.
Modes of presentation included documented SVT in 38%, palpitations in 22%, chest pain in 5%, syncope in 4%, AF in 0.4%, and sudden cardiac death (SCD) in 0.2%.
A confounding factor in diagnosing SVT is the need to differentiate symptoms of SVT from symptoms of panic and anxiety disorders or any condition of heightened awareness of sinus tachycardia (such as postural orthostatic tachycardia syndrome). When AVNRT and AVRT are compared, symptoms appear to differ substantially. Patients with AVNRT more frequently describe symptoms of “shirt flapping” or “neck pounding”
Combined evaluation of bedside clinical variables and the electrocardiogram for the differential diagnosis of paroxysmal atrioventricular reciprocating tachycardias in patients without pre-excitation.
that may be related to pulsatile reversed flow when the right atrium contracts against a closed tricuspid valve (cannon a-waves).
True syncope is infrequent with SVT, but complaints of light-headedness are common. In patients with WPW syndrome, syncope should be taken seriously but is not necessarily associated with increased risk of SCD.
yet the rate alone does not explain symptoms of near-syncope. Elderly patients with AVNRT are more prone to syncope or near-syncope than are younger patients, but the tachycardia rate is generally slower in the elderly.
Electrophysiologic characteristics and results of radiofrequency catheter ablation in elderly patients with atrioventricular nodal reentrant tachycardia.
In a study on the relationship of SVT with driving, 57% of patients with SVT experienced an episode while driving, and 24% of these considered it to be an obstacle to driving.
This sentiment was most common in patients who had experienced syncope or near-syncope. Among patients who experienced SVT while driving, 77% felt fatigue, 50% had symptoms of near-syncope, and 14% experienced syncope. Women had more symptoms in each category.
2.3.2 Evaluation of the ECG
A 12-lead ECG obtained during tachycardia and during sinus rhythm may reveal the etiology of tachycardia. For the patient who describes prior, but not current, symptoms of palpitations, the resting ECG can identify pre-excitation that should prompt a referral to a cardiac electrophysiologist.
For a patient presenting in SVT, the 12-lead ECG can potentially identify the arrhythmia mechanism (Figure 1). If the SVT is regular, this may represent AT with 1:1 conduction or an SVT that involves the atrioventricular (AV) node. Junctional tachycardias, which originate in the AV junction (including the His bundle), can be regular or irregular, with variable conduction to the atria. SVTs that involve the AV node as a required component of the tachycardia reentrant circuit include AVNRT (Section 6) and AVRT (Section 7). In these reentrant tachycardias, the retrogradely conducted P wave may be difficult to discern, especially if bundle-branch block is present. In typical AVNRT, atrial activation is nearly simultaneous with the QRS, so the terminal portion of the P wave is usually located at the end of the QRS complex, appearing as a narrow and negative deflection in the inferior leads (a pseudo S wave) and a slightly positive deflection at the end of the QRS complex in lead V1 (pseudo R′). In orthodromic AVRT (with anterograde conduction down the AV node), the P wave can usually be seen in the early part of the ST-T segment. In typical forms of AVNRT and AVRT, because the P wave is located closer to the prior QRS complex than the subsequent QRS complex, the tachycardias are referred to as having a“short RP.” In unusual cases of AVNRT (such as “fast-slow”), the P wave is closer to the subsequent QRS complex, providing a long RP. The RP is also long during an uncommon form of AVRT, referred to as the permanent form of junctional reciprocating tachycardia (PJRT), in which an unusual accessory bypass tract with “decremental” (slowly conducting) retrograde conduction during orthodromic AVRT produces delayed atrial activation and a long RP interval.
Figure 1Differential diagnosis for adult narrow QRS tachycardia. Patients with junctional tachycardia may mimic the pattern of slow-fast AVNRT and may show AV dissociation and/or marked irregularity in the junctional rate. *RP refers to the interval from the onset of surface QRS to the onset of visible P wave (note that the 90-ms interval is defined from the surface ECG,
Electrocardiographic differentiation of common type atrioventricular nodal reentrant tachycardia from atrioventricular reciprocating tachycardia via a concealed accessory pathway.
ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias–executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias). Developed in collaboration with NASPE-Heart Rhythm Society.
A long RP interval is typical of AT because the rhythm is driven by the atrium and conducts normally to the ventricles. In AT, the ECG will typically show a P wave with a morphology that differs from the P wave in sinus rhythm. In sinus node re-entry tachycardia, a form of focal AT, the P-wave morphology is identical to the P wave in sinus rhythm.
2.4 Principles of Medical Therapy
See Figure 2 for the algorithm for acute treatment of tachycardia of unknown mechanism and Figure 3 for the algorithm for ongoing management of tachycardia of unknown mechanism. See Appendix 1 in the Online Data Supplement for a table of acute drug therapy for SVT (intravenous administration), Appendix 2 for a table of ongoing drug therapy for SVT (oral administration), and Online Data Supplements 1 to 3 for data supporting Section 2.
Figure 2Acute treatment of regular SVT of unknown mechanism.
Appendix 1Author Relationships With Industry and Other Entities (Relevant)–2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia (April 2014)
Committee Member
Employment
Consultant
Speakers Bureau
Ownership/Partnership/Principal
Personal Research
Institutional, Organizational, or Other Financial Benefit
Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply.
Richard L. Page (Chair)
University of Wisconsin School of Medicine and Public Health–Chair, Department of Medicine
None
None
None
None
None
None
None
José A. Joglar (Vice Chair)
University of Texas Southwestern Medical Center–Professor of Internal Medicine; Program Director, Clinical Cardiac Electrophysiology
None
None
None
None
None
None
None
Sana M. Al-Khatib
Duke Clinical Research Institute–Associate Professor of Medicine
None
None
None
None
None
None
None
Mary A. Caldwell
University of California San Francisco–Assistant Professor (Retired)
None
None
None
None
None
None
None
Hugh Calkins
Johns Hopkins Hospital–Professor of Medicine, Director of Electrophysiology
Feinberg School of Medicine, Northwestern University–Professor of Pediatrics; Ann & Robert H. Lurie Children’s Hospital of Chicago–Division Head, Cardiology
None
None
None
None
None
None
None
N.A. Mark Estes III
Tufts University School of Medicine–Professor of Medicine
All Sections except 2.4, 5.2, 6.1.2, 9.3.2, and 9.4.
Win-Kuang Shen
Mayo Clinic Arizona–Professor of Medicine; Chair, Division of Cardiovascular Diseases
None
None
None
None
None
None
None
Cynthia M. Tracy
George Washington University–Professor of Medicine; Associate Director Division of Cardiology, Director of Cardiac Services
None
None
None
None
None
None
None
This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document. These relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the writing committee during the document development process. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of ≥5% of the voting stock or share of the business entity, or ownership of ≥$5,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted.
According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) the person or a member of the person’s household, has a reasonable potential for financial, professional or other personal gain or loss as a result of the issues/content addressed in the document.
ACC indicates American College of Cardiology; AHA, American Heart Association; DSMB, data safety monitoring board; and HRS, Heart Rhythm Society.
* Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply.
Appendix 2Reviewer Relationships With Industry and Other Entities (Relevant)–2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia (March 2015)
Reviewer
Representation
Employment
Consultant
Speakers Bureau
Ownership/Partnership/Principal
Personal Research
Institutional, Organizational, or Other Financial Benefit
Expert Witness
Eugene H. Chung
Official Reviewer–HRS
University of North Carolina School of Medicine–Associate Professor of Medicine
Content Reviewer–ACC Adult Congenital and Pediatric Cardiology Section
Sibley Heart Center Cardiology–Director, Chief of Cardiac Services; Emory University School of Medicine–Division Director of Pediatric Cardiology, Professor of Pediatrics
None
None
None
None
None
None
Susan P. Etheridge
Content Reviewer–ACC Adult Congenital and Pediatric Cardiology Section
University of Utah–Training Program Director
None
None
None
None
None
None
Paul A. Friedman
Content Reviewer
Mayo Clinic–Professor of Medicine; Cardiovascular Implantable Device Laboratory–Director
University of Nebraska Medical Center–Division Chief of Pediatric Cardiology
None
None
None
None
None
None
Fred M. Kusumoto
Content Reviewer
Mayo Clinic–Professor of Medicine
None
None
None
None
None
None
Glenn N. Levine
Content Reviewer–ACC/AHA Task Force on Clinical Practice Guidelines
Baylor College of Medicine–Professor of Medicine; Director, Cardiac Care Unit
None
None
None
None
None
None
Marco A. Mercader
Content Reviewer
George Washington University–Associate Professor of Medicine
None
None
None
None
None
None
William M. Miles
Content Reviewer
University of Florida–Professor of Medicine, Silverstein Chair for Cardiovascular Education, Director of the Clinical Cardiac Electrophysiology Fellowship Program
None
None
None
None
•
Medtronic (DSMB)
None
Fred Morady
Content Reviewer
University of Michigan–McKay Professor of Cardiovascular Disease
None
None
None
None
None
None
Melvin M. Scheinman
Content Reviewer
University of California San Francisco–Professor of Medicine
University of the Sciences, Philadelphia College of Pharmacy–Professor of Clinical Pharmacy
•
Portola Pharmaceuticals
None
None
None
None
None
William G. Stevenson
Content Reviewer
Brigham and Women’s Hospital–Director, Clinical Cardiac Electrophysiology Program
•
St. Jude Medical
None
None
None
None
None
Albert L. Waldo
Content Reviewer
University Hospitals–Associate Chief of Cardiovascular Medicine for Academic Affairs; Case Western Reserve University School of Medicine–Professor of Medicine
University of Texas Southwestern Medical Center–Professor of Internal Medicine, Director of Cardiac Electrophysiology Lab
None
None
None
•
Boehringer Ingelheim
•
Janssen Pharmaceutical
•
Medtronic
None
None
This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant to this document. It does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of ≥5% of the voting stock or share of the business entity, or ownership of ≥$5,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. A relationship is considered to be modest if it is less than significant under the preceding definition. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of review.
According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) the person or a member of the person’s household, has a reasonable potential for financial, professional or other personal gain or loss as a result of the issues/content addressed in the document.
ACC indicates American College of Cardiology; AHA, American Heart Association; DSMB, data safety monitoring board; and HRS, Heart Rhythm Society.
emergency physicians may be the first to evaluate patients whose tachycardia mechanism is unknown and to have the opportunity to diagnose the mechanism of arrhythmia. It is important to record a 12-lead ECG to differentiate tachycardia mechanisms according to whether the AV node is an obligate component (Section 2.3.2), because treatment that targets the AV node will not reliably terminate tachycardias that are not AV node dependent.
Tabled
1Recommendations for Acute Treatment of SVT of Unknown Mechanism
COR
LOE
Recommendations
I
B-R
1. Vagal maneuvers are recommended for acute treatment in patients with regular SVT.
Adenosine for paroxysmal supraventricular tachycardia: dose ranging and comparison with verapamil. Assessment in placebo-controlled, multicenter trials. The Adenosine for PSVT Study Group.
3. Synchronized cardioversion is recommended for acute treatment in patients with hemodynamically unstable SVT when vagal maneuvers or adenosine are ineffective or not feasible.
4. Synchronized cardioversion is recommended for acute treatment in patients with hemodynamically stable SVT when pharmacological therapy is ineffective or contraindicated.
The recommendations and algorithm (Figure 3) for ongoing management, along with other recommendations and algorithms for specific SVTs that follow, are meant to include consideration of patient preferences and clinical judgment; this may include consideration of consultation with a cardiologist or clinical cardiac electrophyisiologist, as well as patient comfort with possible invasive diagnostic and therapeutic intervention. Recommendations for treatment options (including drug therapy, ablation, or observation) must be considered in the context of frequency and duration of the SVT, along with clinical manifestations, such as symptoms or adverse consequences (e.g., development of cardiomyopathy).
Tabled
1Recommendations for Ongoing Management of SVT of Unknown Mechanism
COR
LOE
Recommendations
I
B-R
1. 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.
The Multicentre European Radiofrequency Survey (MERFS): complications of radiofrequency catheter ablation of arrhythmias. The Multicentre European Radiofrequency Survey (MERFS) investigators of the Working Group on Arrhythmias of the European Society of Cardiology.
Incidence of complete atrioventricular block following attempted radiofrequency catheter modification of the atrioventricular node in 880 patients. Results of the Multicenter European Radiofrequency Survey (MERFS) The Working Group on Arrhythmias of the European Society of Cardiology.
Catheter ablation of accessory pathways, atrioventricular nodal reentrant tachycardia, and the atrioventricular junction: final results of a prospective, multicenter clinical trial. The Atakr Multicenter Investigators Group.
1. Flecainide or propafenone is reasonable for ongoing management in patients without structural heart disease or ischemic heart disease who have symptomatic SVT and are not candidates for, or prefer not to undergo, catheter ablation.
Efficacy and safety of dofetilide in the prevention of symptomatic episodes of paroxysmal supraventricular tachycardia: a 6-month double-blind comparison with propafenone and placebo.
A randomized, placebo-controlled trial of propafenone in the prophylaxis of paroxysmal supraventricular tachycardia and paroxysmal atrial fibrillation. UK Propafenone PSVT Study Group.
Safety of flecainide versus propafenone for the long-term management of symptomatic paroxysmal supraventricular tachyarrhythmias. Report from the Flecainide and Propafenone Italian Study (FAPIS) Group.
Flecainide acetate treatment of paroxysmal supraventricular tachycardia and paroxysmal atrial fibrillation: dose-response studies. The Flecainide Supraventricular Tachycardia Study Group.
Flecainide acetate prevents recurrence of symptomatic paroxysmal supraventricular tachycardia. The Flecainide Supraventricular Tachycardia Study Group.
1. Sotalol may be reasonable for ongoing management in patients with symptomatic SVT who are not candidates for, or prefer not to undergo, catheter ablation.
Multicenter comparative study of the efficacy and safety of sotalol in the prophylactic treatment of patients with paroxysmal supraventricular tachyarrhythmias.
2. 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.
Efficacy and safety of dofetilide in the prevention of symptomatic episodes of paroxysmal supraventricular tachycardia: a 6-month double-blind comparison with propafenone and placebo.
3. 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.
Comparison of electrophysiologic effects and efficacy of single-dose intravenous and long-term oral amiodarone therapy in patients with AV nodal reentrant tachycardia.
4. 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.
2.5 Basic Principles of Electrophysiological Study, Mapping, and Ablation
An invasive EP study permits the precise diagnosis of the underlying arrhythmia mechanism and localization of the site of origin and provides definitive treatment if coupled with catheter ablation. There are standards that define the equipment and training of personnel for optimal performance of EP study.
EP studies involve placement of multielectrode catheters in the heart at ≥1 sites in the atria, ventricles, or coronary sinus. Pacing and programmed electrical stimulation may be performed with or without pharmacological provocation. By using diagnostic maneuvers during the EP study, the mechanism of SVT can be defined in most cases
A table of success and complication rates for ablation of SVT is included in the full-text guideline and in the Online Data Supplement–Appendix 3. Cardiac mapping is performed during EP studies to identify the site of origin of an arrhythmia or areas of critical conduction to allow targeting of ablation. Multiple techniques have been developed to characterize the temporal and spatial distribution of electrical activation.
Several tools have been developed to facilitate arrhythmia mapping and ablation, including electroanatomic 3-dimensional mapping and magnetic navigation. Potential benefits of these technologies include more precise definition or localization of arrhythmia mechanism, spatial display of catheters and arrhythmia activation, reduction in fluoroscopy exposure for the patient and staff, and shortened procedure times, particularly for complex arrhythmias or anatomy.
Fluoroscopy has historically been the primary imaging modality used for EP studies. Attention to optimal fluoroscopic technique and adoption of radiation-reducing strategies can minimize radiation dose to the patient and operator. The current standard is to use the “as low as reasonably achievable” (ALARA) principle on the assumption that there is no threshold below which ionizing radiation is free from harmful biological effect. Alternative imaging systems, such as electroanatomic mapping and intracardiac echocardiography, have led to the ability to perform SVT ablation with no or minimal fluoroscopy, with success and complication rates similar to standard techniques.
“Near-zero” fluoroscopic exposure in supraventricular arrhythmia ablation using the EnSite NavX mapping system: personal experience and review of the literature.
Effect of electroanatomically guided versus conventional catheter ablation of typical atrial flutter on the fluoroscopy time and resource use: a prospective randomized multicenter study.
Cryoablation is used as an alternative to radiofrequency ablation to minimize injury to the AV node during ablation of specific arrhythmias, such as AVNRT, para-Hisian AT, and para-Hisian accessory pathways, particularly in specific patient populations, such as children and young adults. Selection of the energy source depends on operator experience, arrhythmia target location, and patient preference.
3. Sinus Tachyarrhythmias
In normal individuals, the sinus rate at rest is generally between 50 bpm and 90 bpm, reflecting vagal tone.
Sinus tachycardia refers to the circumstance in which the sinus rate exceeds 100 bpm. On the ECG, the P wave is upright in leads I, II, and aVF and is biphasic in lead V1.
3.1 Physiological Sinus Tachycardia
Physiological sinus tachycardia may result from pathological causes, including infection with fever, dehydration, anemia, heart failure, and hyperthyroidism, in addition to exogenous substances, including caffeine, drugs with a beta-agonist effect (e.g., albuterol, salmeterol), and illicit stimulant drugs (e.g., amphetamines, cocaine). In these cases, tachycardia is expected to resolve with correction of the underlying cause.
3.2 Inappropriate Sinus Tachycardia
Inappropriate sinus tachycardia (IST) is defined as sinus tachycardia that is unexplained by physiological demands. Crucial to this definition is the presence of associated, sometimes debilitating, symptoms that include weakness, fatigue, lightheadedness, and uncomfortable sensations, such as heart racing. Patients with IST commonly show resting heart rates >100 bpm and average rates that are >90 bpm in a 24-hour period.
The cause of IST is unclear, and mechanisms related to dysautonomia, neurohormonal dysregulation, and intrinsic sinus node hyperactivity have been proposed.
It is important to distinguish IST from secondary causes of tachycardia, including hyperthyroidism, anemia, dehydration, pain, and use of exogenous substances. Anxiety is also an important trigger, and patients with IST may have associated anxiety disorders.
IST must also be distinguished from other forms of tachycardia, including AT arising from the superior aspect of the crista terminalis and sinus node reentrant tachycardia (Section 4). It is also important to distinguish IST from postural orthostatic tachycardia syndrome, although overlap may be present within an individual. Patients with postural orthostatic tachycardia syndrome have predominant symptoms related to a change in posture, and treatment to suppress the sinus rate may lead to severe orthostatic hypotension. Thus, IST is a diagnosis of exclusion.
3.2.1 Acute Treatment
There are no specific recommendations for acute treatment of IST.
3.2.2 Ongoing Management: Recommendations
Because the prognosis of IST is generally benign, treatment is for symptom reduction and may not be necessary. Treatment of IST is difficult, and it should be recognized that lowering the heart rate may not alleviate symptoms. Therapy with beta blockers or calcium channel blockers is often ineffective or not well tolerated because of cardiovascular side effects, such as hypotension. Exercise training may be of benefit, but the benefit is unproven.
Ivabradine is an inhibitor of the “I-funny” or “If” channel, which is responsible for normal automaticity of the sinus node; therefore, ivabradine reduces the sinus node pacemaker activity, which results in slowing of the heart rate. On the basis of the results of 2 large, randomized, placebo-controlled trials, this drug was recently approved by the FDA for use in patients with systolic heart failure. The drug has no other hemodynamic effects aside from lowering the heart rate. As such, it has been investigated for use to reduce the sinus rate and improve symptoms related to IST.
Clinical efficacy of ivabradine in patients with inappropriate sinus tachycardia: a prospective, randomized, placebo-controlled, double-blind, crossover evaluation.
Ivabradine in the treatment of inappropriate sinus tachycardia in patients after successful radiofrequency catheter ablation of atrioventricular node slow pathway.
Efficacy of ivabradine in four patients with inappropriate sinus tachycardia: a three month-long experience based on electrocardiographic, Holter monitoring, exercise tolerance and quality of life assessments.
Radiofrequency ablation to modify the sinus node can reduce the sinus rate, with acute procedural success rates reported in the range of 76% to 100% in nonrandomized cohorts.
Narrowing of the superior vena cava-right atrium junction during radiofrequency catheter ablation for inappropriate sinus tachycardia: analysis with intracardiac echocardiography.
Frequent additional tachyarrhythmias in patients with inappropriate sinus tachycardia undergoing sinus node modification: an important cause of symptom recurrence.
Usefulness of non-contact mapping for radiofrequency catheter ablation of inappropriate sinus tachycardia: new procedural strategy and long-term clinical outcome.
Nonetheless, symptoms commonly recur after several months, with IST recurrence in up to 27% and overall symptomatic recurrence (IST or non-IST AT) in 45% of patients.
Frequent additional tachyarrhythmias in patients with inappropriate sinus tachycardia undergoing sinus node modification: an important cause of symptom recurrence.
Complications can be significant. In view of the modest benefit of this procedure and its potential for significant harm, sinus node modification should be considered only for patients who are highly symptomatic and cannot be adequately treated by medication, and then only after informing the patient that the risks may outweigh the benefits of ablation.
Clinical efficacy of ivabradine in patients with inappropriate sinus tachycardia: a prospective, randomized, placebo-controlled, double-blind, crossover evaluation.
Ivabradine in the treatment of inappropriate sinus tachycardia in patients after successful radiofrequency catheter ablation of atrioventricular node slow pathway.
Efficacy of ivabradine in four patients with inappropriate sinus tachycardia: a three month-long experience based on electrocardiographic, Holter monitoring, exercise tolerance and quality of life assessments.
Presence and severity of symptoms during focal ATs are variable among patients. Focal AT in the adult population is usually associated with a benign prognosis, although AT-mediated cardiomyopathy has been reported in up to 10% of patients referred for ablation of incessant SVT.
Nonsustained focal AT is common and often does not require treatment.
The diagnosis of focal AT is suspected when the ECG criteria are met (Section 2). Algorithms have been developed to estimate the origin of the focal AT from the P-wave morphology recorded on a standard 12-lead ECG.
Sustained atrial tachycardia in adult patients. Electrophysiological characteristics, pharmacological response, possible mechanisms, and effects of radiofrequency ablation.
Electrophysiological and electrocardiographic characteristics of focal atrial tachycardia originating from the pulmonary veins: acute and long-term outcomes of radiofrequency ablation.
Focal atrial tachycardia from the ostium of the coronary sinus: electrocardiographic and electrophysiological characterization and radiofrequency ablation.
Focal atrial tachycardias arising from the right atrial appendage: electrocardiographic and electrophysiologic characteristics and radiofrequency ablation.
Sinus node reentrant tachycardia is an uncommon type of focal AT that involves a microreentrant circuit in the region of the sinoatrial node, causing a P-wave morphology that is identical to that of sinus tachycardia (although this is not sinus tachycardia). Characteristics that distinguish sinus node reentry from sinus tachycardia are an abrupt onset and termination and often a longer RP interval than that observed during normal sinus rhythm.
4.1.1 Acute Treatment: Recommendations
RCTs of drug therapy for comparative effectiveness in patients with focal AT in the acute setting are not available. Many of the clinical outcomes are reported from small observational studies that included infants or pediatric patients.
Sustained atrial tachycardia in adult patients. Electrophysiological characteristics, pharmacological response, possible mechanisms, and effects of radiofrequency ablation.
1. Adenosine can be useful in the acute setting to either restore sinus rhythm or diagnose the tachycardia mechanism in patients with suspected focal AT.
Sustained atrial tachycardia in adult patients. Electrophysiological characteristics, pharmacological response, possible mechanisms, and effects of radiofrequency ablation.
1. Intravenous 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.
Sustained atrial tachycardia in adult patients. Electrophysiological characteristics, pharmacological response, possible mechanisms, and effects of radiofrequency ablation.
Electrophysiological and electrocardiographic characteristics of focal atrial tachycardia originating from the pulmonary veins: acute and long-term outcomes of radiofrequency ablation.
Focal atrial tachycardias arising from the right atrial appendage: electrocardiographic and electrophysiologic characteristics and radiofrequency ablation.
Spanish Catheter Ablation Registry. 12th Official Report of the Spanish Society of Cardiology Working Group on Electrophysiology and Arrhythmias (2012).
Sustained atrial tachycardia in adult patients. Electrophysiological characteristics, pharmacological response, possible mechanisms, and effects of radiofrequency ablation.
2. Flecainide or propafenone can be effective for ongoing management in patients without structural heart disease or ischemic heart disease who have focal AT.
MAT is defined in Table 2. The mechanism of MAT is not well established. MAT is commonly associated with underlying conditions, including pulmonary disease, pulmonary hypertension, coronary disease, and valvular heart disease,
The first-line treatment is management of the underlying condition. Intravenous magnesium may also be helpful in patients with normal magnesium levels.
Tabled
1Recommendations for Ongoing Management of Multifocal Atrial Tachycardia
COR
LOE
Recommendation
IIa
B-NR C-LD
1. Oral verapamil (Level of Evidence: B-NR) or diltiazem (Level of Evidence: C-LD) is reasonable for ongoing management in patients with recurrent symptomatic MAT.
See Figure 6 for the algorithm for acute treatment of AVNRT, Figure 7 for the algorithm for ongoing management of AVNRT, and Online Data Supplements 9 and 10 for additional data supporting Section 5.
AVNRT is the most common SVT and is defined in Table 2. It is usually seen in young adults without structural heart disease or ischemic heart disease, and >60% of cases are observed in women.
Combined evaluation of bedside clinical variables and the electrocardiogram for the differential diagnosis of paroxysmal atrioventricular reciprocating tachycardias in patients without pre-excitation.
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