Supraventricular Tachycardia Clinical Practice Guidelines (2019)

European Society of Cardiology (ESC), Association for European Paediatric and Congenital Cardiology (AEPC)

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

October 01, 2019

The recommendations on the management of supraventricular tachycardia (SVT) were released in August 2019 by the European Society of Cardiology (ESC) in collaboration with the Association for European Paediatric and Congenital Cardiology (AEPC).[1,2] Several changes from the previous guidelines (2003) include revised drug grades as well as medications that are no longer considered, and changes to ablation techniques and indications.

Table. Medications, Strategies, and Techniques Specified or Not Mentioned in the 2019 Guidelines

Type of Tachycardia Treatment (Grade) Not Mentioned in 2019 Guidelines
Narrow QRS tachycardias Verapamil and diltiazem; beta-blockers (now all are grade IIa) Amiodarone, digoxin
Wide QRS tachycardias Procainamide, adenosine (both grade IIa); amiodarone (IIb) Sotalol, lidocaine
Inappropriate sinus tachycardia Beta-blockers (IIa) Verapamil/diltiazem, catheter ablation
Postural orthostatic tachycardia syndrome Salt and fluid intake (IIb) Head-up tilt sleep, compression stockings, selective beta-blockers, fludrocortisone, clonidine, methylphenidate, fluoxetine, erythropoietin, ergotaminel octreotide, phenobarbitone
Focal atrial tachycardia Acute: beta-blockers (IIa); flecainide/propafenone, amiodarone (IIb) Acute: procainamide, sotalol, digoxin
Chronic: beta-blockers; verapamil and diltiazem (all IIa) Chronic: amiodarone, sotalol, disopyramide
Atrial flutter Acute: ibutilide (I); verapamil and diltiazem, beta-blockers (all IIa); atrial or transesophageal pacing (IIb); flecainide/propafenone (III) Acute: digitalis
Chronic: Chronic: dofetilide, sotalol, flecainide, propafenone, procainamide, quinidine, disopyramide
Atrioventricular nodal re-entrant tachycardia (AVNRT) Acute: Acute: amiodarone, sotalol, flecainide, propafenone
Chronic: verapamil and diltiazem; beta-blockers (all IIa) Chronic: amiodarone, sotalol, flecainide, propafenone, “pill-in-the-pocket” approach
Atrioventricular re-entrant tachycardia (AVRT) Beta-blockers (IIa); flecainide/propafenone (IIb) Amiodarone, sotalol, “pill-in-the-pocket” approach
SVT in pregnancy Verapamil (IIa); catheter ablation (IIa when fluoroless ablation is available) Sotalol, propafenone, quinidine, procainamide
Adapted from Brugada J, Katritsis DG, Arbelo E, et al, for the ESC Scientific Document Group. 2019 ESC Guidelines for the management of patients with supraventricular tachycardia. The Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J. 2019 Aug 31;ehz467. https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehz467/5556821

2019 New Recommendations

For detailed recommendations on specific types of SVTs, please consult the original guidelines as listed under the references.

Class I (recommended or indicated)

For conversion of atrial flutter: Intravenous (IV) ibutilide, or IV or oral (PO) (in-hospital) dofetilide

For termination of atrial flutter (when an implanted pacemaker or defibrillator is present): High-rate atrial pacing

For asymptomatic patients with high-risk features (eg, shortest pre-excited RR interval during atrial fibrillation [SPERRI] ≤250 ms, accessory pathway [AP] effective refractory period [ERP] ≤250 ms, multiple APs, and an inducible AP-mediated tachycardia) as identified on electrophysiology testing (EPS) using isoprenaline: Catheter ablation

For tachycardia responsible for tachycardiomyopathy that cannot be ablated or controlled by drugs: Atrioventricular nodal ablation followed by pacing (“ablate and pace”) (biventricular or His-bundle pacing)

First trimester of pregnancy: Avoid all antiarrhythmic drugs, if possible

Class IIa (should be considered)

Symptomatic patients with inappropriate sinus tachycardia: Consider ivabradine alone or with a beta-blocker

Atrial flutter without atrial fibrillation: Consider anticoagulation (initiation threshold not yet established)

Asymptomatic preexcitation: Consider EPS for risk stratification

Asymptomatic preexcitation with left ventricular dysfunction due to electrical dyssynchrony: Consider catheter ablation

Class IIb (may be considered)

Acute focal atrial tachycardia: Consider IV ibutilide

Chronic focal atrial tachycardia: Consider ivabradine with a beta-blocker

Postural orthostatic tachycardia syndrome: Consider ivabradine

Asymptomatic preexcitation: Consider noninvasive assessment of the AP conducting properties

Asymptomatic preexcitation with low-risk AP at invasive/noninvasive risk stratification: Consider catheter ablation

Prevention of SVT in pregnant women without Wolff-Parkinson-White syndrome: Consider beta-1 selective blockers (except atenolol) (preferred) or verapamil

Prevention of SVT in pregnant women with Wolff-Parkinson-White syndrome and without ischemic or structural heart disease: Consider flecainide or propafenone

Class III (not recommended)

IV amiodarone is not recommended for preexcited atrial fibrillation.

For more information, please go to Atrial Tachycardia, Atrial Fibrillation, Atrial Flutter, and Atrioventricular Nodal Reentry Tachycardia.

For more Clinical Practice Guidelines, please go to Guidelines.

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