Definitions for the weight of the evidence (A-C) and classes of recommendations (I-III) can be found at the end of the "Major Recommendations" field.
Note: The order in which treatment recommendations appear in the following tables within each class of recommendation does not necessarily reflect a preferred sequence of administration. Please refer to the original guideline document for details. For pertinent drug dosing information, please refer to the National Guideline Clearinghouse summary ACC/AHA/ESC Guidelines on the Management of Patients With Atrial Fibrillation.
Recommendations for Acute Management of Hemodynamically Stable and Regular Tachycardia
ECG |
Recommendation1 |
Classification |
Level of Evidence |
References |
Narrow QRS-complex tachycardia (SVT) |
Vagal maneuvers |
I |
B |
|
Adenosine |
I |
A |
Glatter et al., 1999; Cairns & Niemann, 1991; Rankin et al., 1992 |
Verapamil, diltiazem |
I |
A |
Waxman et al., 1981 |
Beta blockers |
IIb |
C |
Amsterdam, Kulcyski & Ridgeway, 1991; Das et al., 1988 |
Amiodarone |
IIb |
C |
Holt et al., 1985 |
Digoxin |
IIb |
C |
|
Wide QRS-complex tachycardia |
|
See above |
|
|
|
|
Flecainide3 |
I |
B |
Hohnloser & Zabel, 1992 |
Ibutilide3 |
I |
B |
Glatter, Dorostkar & Yang, 2001 |
Procainamide3 |
I |
B |
|
DC cardioversion |
I |
C |
|
- Wide QRS-complex tachycardia of unknown origin
|
Procainamide3 |
I |
B |
Gorgels et al., 1996; Manz et al., 1992 |
Sotalol3 |
I |
B |
Ho et al., 1994 |
Amiodarone |
I |
B |
Boineau et al., 1980; Scheinman et al., 1995 |
DC cardioversion |
I |
B |
Part 1: Introduction to the International Guidelines 2000 for CPR and ECC, 2000 |
Lidocaine |
IIb |
B |
Manz et al., 1992; Ho et al., 1994 |
Adenosine4 |
IIb |
C |
Sharma, Klein & Yee, 1990 |
Beta blockers5 |
III |
C |
Part 1: Introduction to the International Guidelines 2000 for CPR and ECC, 2000 |
Verapamil6 |
III |
B |
Buxton et al., 1987 |
Wide QRS-complex tachycardia of unknown origin in patients with poor LV function |
Amiodarone |
I |
B |
Boineau et al., 1980; Scheinman et al., 1995 |
DC cardioversion, lidocaine |
I |
B |
Part 1: Introduction to the International Guidelines 2000 for CPR and ECC, 2000 |
1All listed drugs are administered intravenously.
2See Section V-D.
3Should not be taken by patients with reduced LV function.
4Adenosine should be used with caution in patients with severe coronary artery disease because vasodilation of normal coronary vessels may produce ischemia in vulnerable territory. It should be used only with full resuscitative equipment available.
5Beta blockers may be used as first-line therapy for those with catecholamine-sensitive tachycardias, such as right ventricular outflow tachycardia.
6Verapamil may be used as first-line therapy for those with LV fascicular VT.
Abbreviations: AF, atrial fibrillation; BBB, bundle-branch block; DC, direct current; ECG, electrocardiogram; LV, left ventricular; QRS, ventricular activation on ECG; SVT, supraventricular tachycardia; VT, ventricular tachycardia
Recommendations for Treatment of Inappropriate Sinus Tachycardia
Treatment |
Recommendation |
Classification |
Level of Evidence |
References |
Medical |
Beta blockers |
I |
C |
|
Verapamil, diltiazem |
IIa |
C |
|
Interventional |
Catheter ablation—sinus node modification/elimination* |
IIb |
C |
Sato et al., 2000; Mischke, Stellbrink & Hanrath, 2001; Man et al., 2000; Lee et al., 1995; Yee et al., 1984; Esmailzadeh et al., 1997; de Paola et al., 1992; Jayaprakash, Sparks & Vohra, 1997 |
*Used as a last resort.
Recommendations for Long-Term Treatment of Patients With Recurrent AVNRT
Clinical Presentation |
Recommendation |
Classification |
Level of Evidence |
References |
Poorly tolerated AVNRT with hemodynamic intolerance |
Catheter ablation |
I |
B |
Akhtar et al., 1993 |
Verapamil, diltiazem, beta blockers, sotalol, amiodarone |
IIa |
C |
Akhtar et al., 1993 |
Flecainide,1 propafenone1 |
IIa |
C |
|
Recurrent symptomatic AVNRT |
Catheter ablation |
I |
B |
Akhtar et al., 1993 |
Verapamil |
I |
B |
Mauritson et al., 1982 |
Diltiazem, beta blockers |
I |
C |
Winniford, Fulton & Hillis, 1984 |
Digoxin2 |
IIb |
C |
|
Recurrent AVNRT unresponsive to beta blockade or calcium-channel blocker and patient not desiring RF ablation |
Flecainide1 propafenone,1 sotalol |
IIa |
B |
Tendera et al., 2001; Anderson et al., 1994; Pritchett, McCarthy & Wilkinson, 1991; Wanless et al., 1997; Henthorn et al., 1991; "A randomized, placebo-controlled trial," 1995 |
Amiodarone |
IIb |
C |
Gambhir et al., 1996 |
AVNRT with infrequent or single episode in patients who desire complete control of arrhythmia |
Catheter ablation |
I |
B |
|
Documented PSVT with only dual AV-nodal pathways or single echo beats demonstrated during electrophysiological study and no other identified cause of arrhythmia |
Verapamil, diltiazem, beta blockers, flecainide1, propafenone1 |
I |
C |
|
Catheter ablation3 |
I |
B |
|
Infrequent, well-tolerated AVNRT |
No therapy |
I |
C |
Akhtar et al., 1993 |
Vagal maneuvers |
I |
B |
|
Pill-in-the-pocket |
I |
B |
|
Verapamil, diltiazem, beta blockers |
I |
B |
|
Catheter ablation |
I |
B |
Bogun et al., 1996 |
1Relatively contraindicated for patients with coronary artery disease, LV dysfunction, or other significant heart disease.
2Digoxin is often ineffective because pharmacological effects can be overridden by enhanced sympathetic tone.
3Decision depends on symptoms.
Abbreviations: AV, atrioventricular; AVNRT, atrioventricular nodal reciprocating tachycardia; LV, left ventricular; PSVT, paroxysmal supraventricular tachycardia; RF, radiofrequency
Recommendations for Treatment of Focal and Nonparoxysmal Junctional Tachycardia Syndromes
Tachycardia |
Recommendation |
Classification |
Level of Evidence |
References |
Focal junctional tachycardia |
Beta blockers |
IIa |
C |
|
Flecainide |
IIa |
C |
Kuck et al., 1988 |
Propafenone1 |
IIa |
C |
Paul et al., 1992 |
Sotalol1 |
IIa |
C |
Maragnes, Fournier & Davignon, 1992 |
Amiodarone1 |
IIa |
C |
Fidell et al., 1973; Villain et al., 1990 |
Catheter ablation |
IIa |
C |
Hamdan, Dorostkar, Scheinmann, 2000; Ehlert et al., 1993; Hamdan et al., 1996; Scheinman et al., 1994 |
Nonparoxysmal junctional tachycardia |
Reverse digitalis toxicity |
I |
C |
Castellanos, Sung & Myerburg, 1979; Storstein et al., 1977 |
Correct hypokalemia |
I |
C |
|
Treat myocardial ischemia |
I |
C |
Fisch, 1970 |
Beta blockers, calcium-channel blockers |
IIa |
C |
Lee et al., 1999; Breslow, Evers & Lebowitz, 1985 |
1Data available for pediatric patients only.
Recommendations for Long-Term Therapy of Accessory Pathway-Mediated Arrhythmias
Arrhythmia |
Recommendation |
Classification |
Level of Evidence |
References |
WPW syndrome (pre-excitation and symptomatic arrhythmias), well tolerated |
Catheter ablation |
I |
B |
Scheinmann & Huang, 2000; Jackman et al., 1991; Manolis, Katsaros & Cokkinos, 1992; Zipes et al., 1995 |
Flecainide, propafenone |
IIa |
C |
Henthorn et al., 1991; Manolis, Katsaros & Cokkinos, 1992; Janousek et al., 1993; Musto et al., 1988; Vignati, Mauri & Figini, 1993; Vassiliadis et al., 1990; Helmy et al., 1990; Kim, Lal & Ruffy, 1986; Cockrell et al., 1991; Hoff et al., 1988; Wiseman et al., 1990; Benditt et al., 1991; Pritchett et al., 1991; Manolis & Estes, 1989 |
Sotalol, amiodarone, beta blockers |
IIa |
C |
Kunze, Schluter & Kuck, 1987; Mason, 1987; Rosenbaum et al., 1974; Wellens et al., 1976; Kappenberger et al., 1984 |
Verapamil, diltiazem, digoxin |
III |
C |
Lai et al., 1993 |
WPW syndrome (with AF and rapid-conduction or poorly tolerated AVRT) |
Catheter ablation |
I |
B |
Scheinman & Huang, 2000; Calkins et al., 1999; Jackman et al., 1991; Calkins et al., 1991; Kuck et al., 1991; Calkins et al., 1992; Lesh et al., 1993; Scheinmann, 1995; Hindricks, 1993 |
AVRT, poorly tolerated (no pre-excitation) |
Catheter ablation |
I |
B |
Scheinman & Huang, 2000; Calkins et al., 1999; Jackman et al., 1991; Calkins et al., 1991; Kuck et al., 1991; Calkins et al., 1992; Lesh et al., 1993; Scheinmann, 1995; Hindricks, 1993 |
Flecainide, propafenone |
IIa |
C |
Henthorn et al., 1991; Manolis, Katsaros & Cokkinos, 1992; Janousek et al., 1993; Musto et al., 1988; Vignati, Mauri & Figini, 1993; Vassiliadis et al., 1990; Helmy et al., 1990; Kim, Lal & Ruffy, 1986; Cockrell et al., 1991; Hoff et al., 1988; Wiseman et al., 1990; Benditt et al., 1991; Pritchett et al., 1991; Manolis & Estes, 1989 |
Sotalol, amiodarone |
IIa |
C |
Kunze, Schluter & Kuck, 1987; Mason, 1987; Rosenbaum et al., 1974; Wellens et al., 1976; Kappenberger et al., 1984 |
Beta blockers |
IIb |
C |
Lai et al., 1993 |
Verapamil, diltiazem, digoxin |
III |
C |
Lai et al., 1993 |
Single or infrequent AVRT episode(s) (no pre-excitation) |
None |
I |
C |
|
Vagal maneuvers |
I |
B |
|
Pill-in-the-pocket—verapamil, diltiazem, beta blockers |
I |
B |
Alboni et al., 2001; Yeh et al., 1985 |
Catheter ablation |
IIa |
B |
Scheinman & Huang, 2000; Calkins et al., 1999; Jackman et al., 1991; Calkins et al., 1991; Kuck et al., 1991; Calkins et al., 1992; Lesh et al., 1993; Scheinman, 1995; Hindricks, 1993 |
Sotalol, amiodarone |
IIb |
B |
Kunze, Schluter & Kuck, 1987; Mason, 1987; Rosenbaum et al., 1974; Wellens et al., 1976; Kappenberger et al., 1984 |
Flecainide, propafenone |
IIb |
C |
Henthorn et al., 1991; Manolis, Katsaros & Cokkinos, 1992; Janousek et al., 1993; Musto et al., 1988; Vignati, Mauri & Figini, 1993; Vassiliadis et al., 1990; Helmy et al., 1990; Kim, Lal & Ruffy, 1986; Cockrell et al., 1991; Hoff et al., 1988; Wiseman et al., 1990; Benditt et al., 1991; Pritchett et al., 1991; Manolis & Estes, 1989; Lai et al., 1993 |
Digoxin |
III |
C |
|
Pre-excitation, asymptomatic |
None |
I |
C |
|
Catheter ablation |
IIa |
B |
Scheinman & Huang, 2000; Calkins et al., 1999; Jackman et al., 1991; Calkins et al., 1991; Kuck et al., 1991; Calkins et al., 1992; Lesh et al., 1993; Scheinman, 1995; Hindricks, 1993 |
Abbreviations: AF, atrial fibrillation; AVRT, atrioventricular reciprocating tachycardia; WPW, Wolff-Parkinson-White
Recommendations for Treatment of Focal Atrial Tachycardias1
Clinical Situation |
Recommendation |
Classification |
Level of Evidence |
References |
Acute treatment2 |
A. Conversion |
Hemodynamically unstable patient |
DC cardioversion |
I |
B |
|
Hemodynamically stable patient |
Adenosine |
IIa |
C |
Markowitz et al., 1999; Engelstein et al., 1994 |
Beta blockers |
IIa |
C |
Harrison et al., 2001; Stock, 1966 |
Verapamil, diltiazem |
IIa |
C |
Steinbeck & Hoffman, 1998; Kunze et al., 1986 |
Procainamide |
IIa |
C |
|
Flecainide/propafenone |
IIa |
C |
Kunze et al., 1986; Berns et al., 1987; Coumel, Leclercq & Assayag, 1984; Lesh, Kalman & Olgin, 1996 |
Amiodarone, sotalol |
IIa |
C |
Wren, 1998; Coumel, Leclercq & Assayag, 1984; Beaufort-Krol & Bink-Boelkens, 1997; Carrasco et al., 1985; Kopelman & Horowitz, 1989; Prager et al., 1993 |
B. Rate regulation (in absence of digitalis therapy) |
Beta blockers |
I |
C |
Harrison et al., 2001; Stock, 1966 |
Verapamil, diltiazem |
I |
C |
Chen et al., 1994 |
Digoxin |
IIb |
C |
|
Prophylactic therapy |
Recurrent symptomatic AT |
Catheter ablation |
I |
B |
Hsieh & Chen, 2002 |
Beta blockers, calcium-channel blockers |
I |
C |
|
Disopyramide3 |
IIa |
C |
Carrasco et al., 1985 |
Flecainide/propafenone3 |
IIa |
C |
Kunze et al., 1986; Coumel, Leclercq & Assayag, 1984; Lesh, Kalman & Olgin, 1996; Creamer, Nathan & Camm, 1985; Pool & Quart, 1988 |
Sotalol, amiodarone |
IIa |
C |
Wren, 1998; Beaufort-Krol & Bink-Boelkens, 1997; Carrasco et al., 1985; Kopelman & Horowitz, 1989 |
Asymptomatic or symptomatic incessant ATs |
Catheter ablation |
I |
B |
|
Nonsustained and asymptomatic |
No therapy |
I |
C |
|
Catheter ablation |
III |
C |
|
1Excluded are patients with MAT in whom beta blockers and sotalol are often contraindicated due to pulmonary disease.
2All listed drugs for acute treatment are taken intravenously.
3Flecainide, propafenone, and disopyramide should not be used unless they are combined with an AV-nodal—blocking agent.
Abbreviations: AT, atrial tachycardia; DC, direct current; MAT, multifocal atrial tachycardia
Recommendations for Acute Management of Atrial Flutter
Clinical Status/Proposed Therapy |
Recommendation1 |
Classification |
Level of Evidence |
References |
Poorly tolerated |
|
DC cardioversion |
I |
C |
|
|
Beta blockers |
IIa |
C |
|
Verapamil or diltiazem |
IIa |
C |
|
Digitalis2 |
IIb |
C |
|
Amiodarone |
IIb |
C |
|
Stable flutter |
|
Atrial or transesophageal pacing |
I |
A |
Doni et al., 2000; Rostas, Antal & Putorek, 1999; Tucker & Wilson, 1993; Doni et al., 1995; Doni et al., 1996 |
DC cardioversion |
I |
C |
Lown, 1967 |
Ibutilide3 |
IIa |
A |
Stambler et al., 1996; Ellenbogen et al., 1996 |
Flecainide4 |
IIb |
A |
Suttorp et al., 1990; Kingma & Suttorp, 1992 |
Propafenone4 |
IIb |
A |
Suttorp et al., 1990; Kingma & Suttorp, 1992 |
Sotalol |
IIb |
C |
Vos et al., 1998; Sung et al., 1995 |
Procainamide4 |
IIb |
A |
Volgman et al., 1998 |
Amiodarone |
IIb |
C |
Hohnloser & Zabel, 1992; Hou et al., 1995 |
|
Diltiazem or verapamil |
I |
A |
Waxman et al., 1981; Schreck, Rivera & Tricarico, 1997; Platia et al., 1989; Goldenberg et al., 1994 |
Beta blockers |
I |
C |
Platia et al., 1989 |
Digitalis2 |
IIb |
C |
Schreck, Rivera & Tricarico, 1997 |
Amiodarone |
IIb |
C |
Hou et al., 1995 |
Cardioversion should be considered only if the patient is anticoagulated (INR equals 2 to 3), the arrhythmia is less than 48 hours in duration, or the TEE shows no atrial clots.
1All drugs are administered intravenously.
2Digitalis may be especially useful for rate control in patients with heart failure.
<3Ibutilide should not be used in patients with reduced LV function.
4Flecainide, propafenone, and procainamide should not be used unless they are combined with an AV-nodal-blocking agent.
Abbreviations: AV, atrioventricular; DC, direct current; INR, international normalized ratio; LV, left ventricular; TEE, transesophageal echocardiography
Recommendations for Long-Term Management of Atrial Flutter
Clinical Status/Proposed Therapy |
Recommendation |
Classification |
Level of Evidence |
References |
First episode and well-tolerated atrial flutter |
Cardioversion alone |
I |
B |
Lown, 1967 |
Catheter ablation1 |
IIa |
B |
Natale et al., 2000 |
Recurrent and well-tolerated atrial flutter |
Catheter ablation1 |
I |
B |
Willems et al., 2000; Kottkamp et al., 2000; Chen et al., 1996 |
Dofetilide |
IIa |
C |
Singh et al., 2000; Pedersen et al., 2001 |
Amiodarone, sotalol, flecainide,2 3 quinidine,2, 3 propafenone,2, 3 procainamide,2 3 disopyramide2 3 |
IIb |
C |
Hohnloser & Zabel, 1992; Benditt et al., 1999; Naccarelli et al., 1996 |
Poorly tolerated atrial flutter |
Catheter ablation1 |
I |
B |
Willems et al., 2000; Kottkamp et al., 2000; Chen et al., 1996 |
Atrial flutter appearing after use of class Ic agents or amiodarone for treatment of AF |
Catheter ablation1 |
I |
B |
Reithmann et al., 2000; Huang et al., 1998 |
Stop current drug and use another |
IIa |
C |
|
Symptomatic non—CTI-dependent flutter after failed antiarrhythmic drug therapy |
Catheter ablation1 |
IIa |
B |
Akar et al., 2001; Chan et al., 2000; Delacretaz et al., 2001 |
1Catheter ablation of the AV junction and insertion of a pacemaker should be considered if catheter ablative cure is not possible and the patient fails drug therapy.
2These drugs should not be taken by patients with significant structural cardiac disease. Use of anticoagulants is identical to that described for patients with AF.
3Flecainide, propafenone, procainamide, quinidine, and disopyramide should not be used unless they are combined with an AV-nodal-blocking agent.
Abbreviations: AF, atrial fibrillation; AV, atrioventricular; CTI, cavotricuspid isthmus
Recommendations for Treatment Strategies for SVT During Pregnancy
Treatment Strategy |
Recommendation |
Classification |
Level of Evidence |
Acute conversion of PSVT |
Vagal maneuver |
I |
C |
Adenosine |
I |
C |
DC cardioversion |
I |
C |
Metoprolol, propranolol |
IIa |
C |
Verapamil |
IIb |
C |
Prophylactic therapy |
Digoxin |
I |
C |
Metoprolol1 |
I |
B |
Propranolol1 |
IIa |
B |
Sotalol,1 flecainide2 |
IIa |
C |
Quinidine, propafenone,2 verapamil |
IIb |
C |
Procainamide |
IIb |
B |
Catheter ablation |
IIb |
C |
Atenolol3 |
III |
B |
Amiodarone |
III |
C |
1Beta-blocking agents should not be taken in the first trimester, if possible.
2Consider AV-nodal—blocking agents in conjunction with flecainide and propafenone for certain tachycardias (see Section V).
3Atenolol is categorized in class C (drug classification for use during pregnancy) by legal authorities in some European countries.
Abbreviations: AV, atrioventricular; DC, direct current; PSVT, paroxysmal supraventricular tachycardia
Recommendations for Treatment of SVTs in Adults With Congenital Heart Disease
Condition |
Recommendation |
Classification |
Level of Evidence |
References |
Failed antiarrhythmic drugs and symptomatic: |
|
|
|
|
|
Catheter ablation in an experienced center |
I |
C |
Nakagawa et al., 2001; Triedman et al., 2001; Triedman et al., 1995; Delacretaz et al., 2001; Hebe et al., 2000; Triedman et al., 2002; Lesh et al., 1994; Triedman et al., 1997 |
- Mustard or Senning repair of transposition of the great vessels
|
Catheter ablation in an experienced center |
I |
C |
Triedman et al., 1995; Delacretaz et al., 2001; Hebe et al., 2000; Triedman et al., 2002 |
Unrepaired asymptomatic ASD not hemodynamically significant |
Closure of the ASD for treatment of the arrhythmia |
III |
C |
Attie et al., 2001; Donti et al., 2001 |
Unrepaired hemodynamically significant ASD with atrial flutter* |
Closure of the ASD combined with ablation of the flutter isthmus |
I |
C |
|
PSVT and Ebstein's anomaly with hemodynamic indications for surgical repair |
Surgical ablation of accessory pathways at the time of operative repair of the malformation at an experienced center |
I |
C |
Huang et al., 2000; Misaki et al., 1995 |
*Conversion and antiarrhythmic drug therapy initial management as described for atrial flutter (see Section V-F).
Abbreviations: ASD, atrial septal defect; PSVT, paroxysmal supraventricular tachycardia
Definitions:
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 evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.
Class IIa: Weight of evidence/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/treatment is not useful or effective and in some cases may be harmful.
Weight of Evidence
- (Highest) Derived from multiple randomized clinical trials
- Intermediate) Data are based on a limited number of randomized trials, nonrandomized studies, or observational registries.
- (Lowest) Primary basis for the recommendation was consensus.