Supraventricular Tachycardia Guideline
- Page RL, Joglar JA, Caldwell MA, et al.
- 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 2016;67:e27-e115.
The following are key points to remember about the 2015 guideline for the management of adult patients with supraventricular tachycardia (SVT):
- For the purposes of this document, the term “supraventricular tachycardia” (SVT) includes any arrhythmia originating above and including the bundle of His, and specifically excludes atrial fibrillation (AF).
- Paroxysmal SVT is a regular, and typically narrow complex tachycardia that is characterized by sudden onset and termination. Its causes include atrioventricular nodal reentrant tachycardia (AVNRT), orthodromic atrioventricular reentrant tachycardia (AVRT) utilizing an accessory pathway, and atrial tachycardia (AT). Patients with recurrent bouts of symptomatic paroxysmal SVT should be considered for electrophysiologic study and catheter ablation.
- The most common tachycardia in patients with the Wolff-Parkinson-White (WPW) syndrome is orthodromic AVRT. AVRT can occur in patients without pre-excitation on the resting electrocardiogram (ECG). In these cases, anterograde conduction over the pathway is not possible or very slow, and the pathway is referred to as “concealed” (as opposed to “manifest”).
- AF with extremely rapid conduction over the accessory pathway (“pre-excited AF”) can lead to syncope and sudden death. Sudden death is more likely to occur in patients with a history of tachycardia (i.e., with prior symptoms), but may be the first manifestation of the accessory pathway. Patients with pre-excited AF and who are otherwise hemodynamically stable should be treated with intravenous ibutilide or procainamide. Intravenous digoxin, intravenous amiodarone, intravenous or oral beta- and calcium-channel blockers may lead to extremely rapid conduction over the accessory pathway and hemodynamic compromise in patients with pre-excited AF, and thus, should be avoided. Oral beta- or calcium-blocker therapy is reasonable for ongoing treatment of AVRT in patients without pre-excitation on the resting ECG.
- Patients with asymptomatic pre-excitation on a 12-lead ECG are said to have a “WPW pattern.” Patients with intermittent pre-excitation on the resting ECG or abrupt loss of pre-excitation during exercise testing are considered to be at low risk for life-threatening arrhythmias. Other patients may be considered for electrophysiologic (EP) study for risk stratification. Catheter ablation of the accessory pathway should be performed if high-risk features are found on EP testing. It is also reasonable to observe patients with a WPW pattern without further evaluation. It is reasonable to consider catheter ablation in individuals who are unable to secure employment (e.g., pilots) because of a WPW pattern.
- Catheter ablation of the cavo-tricuspid isthmus (CTI) should be considered in patients with symptomatic atrial flutter or those in whom the rate cannot be controlled with medical therapy. Patients undergoing catheter ablation of the CTI should be counseled that there is a reasonable chance that they may develop AF during follow-up. Oral anticoagulation for stroke prevention in patients with atrial flutter should be prescribed according to the patient’s risk factors using the common risk stratification schemes for patients with AF.
- The resting heart rate in patients with inappropriate sinus tachycardia (IST) is typically >100 bpm. A diagnosis of IST is made after excluding conditions associated with a heightened sympathetic tone. It is also important to evaluate the possibility of postural orthostatic tachycardia syndrome (POTS) in patients with IST, as the use of beta-blockers may exacerbate the symptoms in the former and may be helpful in the latter. Ivabradine, an inhibitor of the If channel, reduces sinus node automaticity and is useful in patients with IST.
- Patients with adult congenital heart disease and atrial tachycardia/flutter should be treated with oral anticoagulation using the same risk stratification schemes as for AF.
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