Blomström-Lundqvist
ET AL., MANAGEMENT OF PATIENTS WITH Supraventricular
Arrhythmias
J
Am Coll Cardiol 2003;42:1493–531
ACC/AHA/ESC
Guidelines for the Management of Patients With Supraventricular
Arrhythmias
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)
I. INTRODUCTION
A.
Organization of Committee and Evidence Review
Supraventricular
arrhythmias are a group of common rhythm disturbances. The most
common treatment strategies include antiarrhythmic drug therapy
and catheter ablation. Over the last decade, the latter has been
shown to be a highly successful and often curative intervention.
With the advent of new therapeutic interventions and sophisticated
mapping tools, even very complex arrhythmias may be cured. To facilitate
and optimize the management of patients with supraventricular arrhythmias,
the ACCF, the AHA, and the ESC created a committee to establish
guidelines for better management of these heterogeneous tachyarrhythmias.
This document summarizes the management of patients with supraventricular
arrhythmias with recommendations for diagnostic procedures as well
as indications for antiarrhythmic drugs and/or nonpharmacologic
treatments.
The
panel was composed of physicians and scientists at university and
community hospitals. Members were selected to represent experts
from different European countries and from the United States and
to include members of associations or working groups whose activities
and fields of interest were related to the topic of the writing
committee, including the ESC Working Groups on Arrhythmias, Cardiac
Pacing, and Grown-Up Congenital Heart Diseases and the North American
Society of Pacing and Electrophysiology (NASPE-Heart Rhythm Society).
The writing committee was composed of six members representing the
ACCF and the AHA, four members representing the ESC, and one member
representing NASPE. The writing committee was chosen on the basis
of willingness and availability to participate actively in meetings
and the production of the final manuscript. Writing groups are specifically
charged to perform a formal literature review, weigh the strength
of evidence for or against a particular treatment or procedure,
and estimate expected health outcomes where data exist. Patient-specific
modifiers, comorbidities, and issues of patient preference that
might influence the choice of particular tests or therapies are
considered, as are frequency of follow-up and cost effectiveness.
In controversial areas, or with regard to issues without evidence
other than usual clinical practice, a consensus was achieved by
agreement of the expert panel after thorough deliberations.
This
document was peer reviewed by two official external reviewers representing
the American College of Cardiology Foundation, two official external
reviewers representing the American Heart Association, and two official
external reviewers representing the European Society of Cardiology.
The North American Society for Pacing and Electro- physiology-Heart
Rhythm Society assigned one organiza- tional reviewer to the guideline.
In addition, 37 external content reviewers participated in the review
representing the ACC/AHA Task Force on Practice Guidelines, the
ESC Committee for Practice Guidelines, the ACCF Electro- physiology
Committee, the AHA ECG/Arrhythmias Committee, the ESC Working Group
on Arrhythmias, and the ESC Task Force on Grown-Up Congenital Heart
Disease. See Appendix 2 for the names of all reviewers.
The
document was approved for publication by the governing bodies of
the ACCF, AHA, and ESC. These guidelines will be reviewed annually
by the ESC and the ACC/AHA Task Force on Practice Guidelines and
will be considered current unless they are revised or withdrawn
from distribution. The ACC/AHA/ESC Writing Committee to Develop
Guidelines for the Management of Patients With Supraventricular
Tachycardias conducted a comprehensive review of the relevant literature.
Literature searches were conducted in the following databases: PubMed/Medline,
EMBASE, the Cochrane Library (including the Cochrane Database of
Systematic Reviews and the Cochrane Controlled Trials Registry),
and Best Evidence. Searches were limited to English language sources
and to human subjects. The references selected for this document
are exclusively peer-reviewed papers that are representative but
not all-inclusive. Recommendations are evidence-based and derived
primarily from published data. The level of evidence was ranked
as follows: Level A (highest): derived from multiple randomized
clinical trials;
Level
B (intermediate): Data are based on a limited number of randomized
trials, nonrandomized studies, or observational registries;
Level C (lowest): Primary basis for the recommendation was expert
consensus.
Recommendations
follow the format of previous ACC/AHA guidelines for classifying
indications, summarizing both the evidence and expert opinion.
Class
I: Conditions for which there is evidence and/or general agreement
that a given procedure or treatment is useful and effective.
Class
II: Conditions for which there is conflicting evi- dence and/or
a divergence of opinion about the usefulness/efficacy of a procedure
or treatment.
Class IIa: Weight of evidence or opinion is in favor of usefulness/efficacy.
Class IIb: Usefulness/efficacy is less well established by evidence
or opinion.
Class
III: Conditions for which there is evidence and/or general agreement
that the procedure or treatment is not useful/effective and in some
cases may be harmful.
B.
Contents of These Guidelines—Scope
The
purpose of this joint ACC/AHA/ESC document is to provide clinicians
with practical and authoritative guidelines for the management and
treatment of patients with supraventricular arrhythmias (SVA). These
include rhythms emanating from the sinus node, from atrial tissue
(atrial flutter), and from junctional as well as reciprocating or
accessory pathway-mediated tachycardia. This document does not include
recommendations for patients with atrial fibrillation (AF) [see
ACC/AHA/ESC Guidelines for the Management of Patients With Atrial
Fibrillation (1)] or for pediatric
patients with supraventricular arrhythmias. In this document, SVT
is used to describe re-entrant arrhythmias involving the atrioventricular
(AV) junction (atrioventricular nodal reciprocating tachycardia
[AVNRT]), atrium [atrial tachycardia (AT)], or AV-reciprocating
rhythms [atrioventricular reciprocating tachycardia (AVRT)]). For
our purposes, the term “supraventricular arrhythmia”
refers to all types of supraventricular arrhythmias, excluding AF,
as opposed to SVT, which includes AVNRT, AVRT, and AT.
These
guidelines first present a review of the definition, public health,
epidemiology, general mechanisms, and clinical characteristics of
SVT. The management of each specific tachycardia is then presented,
including a review of the existing literature relating to drug versus
catheter ablative therapy. The treatment algorithms include pharmacologic
and nonpharmacologic antiarrhythmic approaches thought to be most
appropriate for each particular condition. Overall, this is a consensus
document that includes evidence and expert opinions from several
countries. The pharmacologic and
|
