• Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ, Campbell WB, Haines DE, Kuck KH, Lerman BB, Miller DD, Shaeffer CW, Stevenson WG, Tomaselli GF. 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 and the European Society of Cardiology Committee for Practice Guidelines. Bethesda (MD): American College of Cardiology Foundation; 2003. 62 p. [537 references]

This is the current release of the guideline.

Supraventricular arrhythmias

Assessment of Therapeutic Effectiveness
Diagnosis
Evaluation
Management
Treatment

Cardiology
Family Practice
Internal Medicine
Obstetrics and Gynecology

Physicians

• To assist physicians in clinical decision making by describing a range of generally acceptable approaches for the diagnosis and management of supraventricular arrhythmias.
• To provide clinicians with practical and authoritative guidelines for the management and treatment of patients with supraventricular arrhythmias by providing recommendations for diagnostic procedures as well as indications for antiarrhythmic drugs and/or nonpharmacologic treatments.

Patients with supraventricular arrhythmias including rhythms emanating from the sinus node, from atrial tissue (atrial flutter), and from junctional as well as reciprocating or accessory pathway-mediated tachycardia

Note: Patients with atrial fibrillation and pediatric patients are not covered. Postural orthostatic tachycardia syndrome is not included because it is not a disorder of the sinus node.

Evaluation

1. Clinical history
2. Physical examination

Diagnosis

1. 12-lead electrocardiogram (ECG)
2. Echocardiographic examination
3. 24-hour Holter
4. Exercise testing
5. Transesophageal atrial recording and stimulation

Management

1. Patient education
   • Elimination of precipitating factors such as caffeine, alcohol, nicotine, recreational drugs, or hyperthyroidism
   • Vagal maneuvers
2. Pharmacologic treatment
   • Adenosine
   • Digoxin
   • Beta-blocking agents (e.g., metoprolol)
   • Nondihydropyridine calcium-channel antagonists (e.g., diltiazem, verapamil)
   • Class Ic drugs (e.g., flecainide, propafenone)
   • Class III drugs (e.g., sotalol, amiodarone, dofetilide)
   • Class Ia drugs (e.g., quinidine, procainamide, disopyramide)
3. Direct current (DC) cardioversion
4. Atrial overdrive pacing
5. Anticoagulant therapy
6. Closure of atrial septal defect
7. Catheter ablation
8. Referral to arrhythmia specialist

Note: Interventions for the treatment of postural orthostatic tachycardia syndrome (POTS) are considered in the original full text guideline but are not specifically recommended since POTS is not a disorder of the sinus node.

• Cardioversion to sinus rhythm
• Maintenance of sinus rhythm
• Recurrence of atrial fibrillation
• Heart rate control
• Death/mortality rate
• Adverse effects of treatment (e.g., hemorrhagic complications)
• Quality of life
• Cost effectiveness

Searches of Electronic Databases

The American College of Cardiology/American Heart Association/European Society of Cardiology (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.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Levels of Evidence

1. (Highest) Derived from multiple randomized clinical trials
2. (Intermediate) Data are based on a limited number of randomized trials, nonrandomized studies, or observational registries.
3. (Lowest) Primary basis for the recommendation was expert consensus.

Review of Published Meta-Analyses
Systematic Review

Not stated

Expert Consensus

The writing committee was composed of six members representing the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA), four members representing the European Society of Cardiology (ESC), and one member representing the North American Society for Pacing and Electrophysiology – Heart Rhythm Society (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.

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 or treatment is not useful/effective and in some cases may be harmful.

A study compared the effect on quality of life between catheter ablation and pharmacologic therapy as an initial strategy for patients with supraventricular tachycardias (SVTs). Both treatments improved quality of life and decreased frequency of disease-specific symptoms, but ablation improved quality of life in more general health categories and resulted in complete amelioration of symptoms in more patients (74 vs. 33%) than did medication. Potential long-term costs were similar for medication and ablation. Among patients who had monthly episodes of supraventricular tachycardias, radiofrequency (RF) ablation was, however, the more effective and less expensive therapy compared with long-term drug therapy.

Another prospective study compared the long-term effects on health outcome of catheter ablation and medical therapy as an initial treatment for patients with newly documented paroxysmal supraventricular tachycardia (PSVT), excluding those with drug-refractory symptoms referred specifically for ablation. At 5-year follow-up, patients who received ablation had improved quality-of-life scores and a reduction in disease-specific symptoms when compared with patients who continued to take medical therapy. More patients reported complete elimination of symptoms with ablation therapy (70%) than did those taking medical therapy (43%). Over 5 years, the average cumulative cost for patients in the medical therapy group was statistically significantly lower than in patients initially treated with ablation therapy: $6249 plus or minus $1421 per patient versus $7507 plus or minus $1098 per patient. It was concluded that patient preference remains the critical determinant in choosing a particular treatment in cases of mildly to moderately symptomatic paroxysmal supraventricular tachycardia.

External Peer Review

This document was peer reviewed by two official external reviewers representing the American College of Cardiology Foundation (ACCF), two official external reviewers representing the American Heart Association (AHA), and two official external reviewers representing the European Society of Cardiology (ESC). The North American Society for Pacing and Electrophysiology-Heart Rhythm Society assigned one organizational 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 American College of Cardiology Foundation Electrophysiology Committee, the AHA Electrocardiogram (ECG)/Arrhythmias Committee, the ESC Working Group on Arrhythmias, and the ESC Task Force on Grown-Up Congenital Heart Disease.

This document was approved by the ACCF Board of Trustees in August 2003, by the AHA Science Advisory and Coordinating Committee in July 2003, and by the ESC Committee for Practice Guidelines in July 2003.

Algorithms are provided in the original guideline document for:

• Initial evaluation of patients with suspected tachycardia
• Differential diagnosis for narrow ventricular activation on electrocardiogram (QRS) tachycardia
• Response of narrow complex tachycardias to adenosine
• Differential diagnosis for wide QRS-complex tachycardia (greater than 120 ms)
• Acute management of patients with hemodynamically stable and regular tachycardia
• Management of atrial flutter depending on hemodynamic stability

Recommendations are evidence-based and derived primarily from published data. The weight of evidence is given for each recommendation (see the "Major Recommendations" field).

Effective management of patients with supraventricular arrhythmias with appropriate use of diagnostic procedures and treatment with pharmacologic and nonpharmacologic antiarrhythmic approaches

Antiarrhythmic Drug Therapy

• A major concern accompanying the use of antiarrhythmic drugs, particularly when treating an arrhythmia that is not life threatening, such as supraventricular tachycardia (SVT), is the occurrence of ventricular proarrhythmia (e.g., torsade de pointes). A number of clinical factors increase the risk of proarrhythmia, including age, gender, fluid and electrolyte abnormalities, the presence of underlying heart disease, abnormalities of drug clearance, polypharmacy, and drug-drug interactions. Drug-induced slowing of the rate of atrial flutter with the production of one-to-one conduction to the ventricle represents a potentially life-threatening form of proarrhythmia unique to the treatment of SVT.
• The potential benefit of class Ic agents should be balanced with the potential risks of proarrhythmia and toxicity. Because atrial tachycardia (ATs) commonly occur in older patients and in the context of structural heart disease, class Ic agents should be used only after coronary artery disease is excluded.
• Potential adverse effects of adenosine include initiation of atrial fibrillation (AF) (1 to 15%), which is usually transient, and may be particularly problematic for those with ventricular pre-excitation. Adenosine should be avoided in patients with severe bronchial asthma. It is important to use extreme care with concomitant use of intravenous (IV) calcium-channel blockers and beta blockers because of possible potentiation of hypotensive and/or bradycardic effects. Hypotension and sinus bradycardia are rare complications of diltiazem plus propranolol.
• Amiodarone is associated with organ toxicity and a high rate of discontinuation.

Intravenous (IV) Antiarrhythmia Drugs

• Intravenous verapamil or diltiazem may be deleterious because they may precipitate hemodynamic collapse for a patient with ventricular tachycardia (VT).
• In a study comparing IV flecainide with propafenone adverse effects included ventricular activation on electrocardiogram (ECG) (QRS) widening, dizziness, and paresthesias.
• In one study adverse effects of IV sotalol included hypotension and dyspnea.
• A review of the existing literature for IV antiarrhythmic drugs taken by patients with atrial flutter suggests that dofetilide or ibutilide are more effective than sotalol or class I agents but are associated with a significant incidence of torsades de pointes (1.5 to 3%).

Antiarrhythmic Drugs During Pregnancy

• Propranolol and metoprolol are generally considered to be safe but are best avoided in the first trimester of pregnancy. Rare cases of adverse effects on the fetus, including bradycardia, hypoglycemia, premature labor, and metabolic abnormalities, have been reported but may be secondary to fetal distress in high-risk pregnancies. The potential for intrauterine growth retardation has been reported with propranolol and has raised concerns, especially when it is taken in the first trimester. Later studies reported growth retardation in babies receiving atenolol in the first trimester and a higher prevalence of preterm delivery.
• The use of amiodarone, a category D agent, in pregnancy should be restricted to arrhythmias that are resistant to other drugs or are life threatening.
• Quinidine is considered to be relatively well tolerated during pregnancy, although isolated cases of adverse effects, such as fetal thrombocytopenia and eighth-nerve toxicity, have been reported

Catheter Ablation

• Potential adverse effects include pericarditis, phrenic nerve injury, superior vena cava (SVC) syndrome, or need for permanent pacing.
• Complications associated with catheter ablation of accessory pathways result from radiation exposure, vascular access (e.g., hematomas, deep venous thrombosis, arterial perforation, arteriovenous fistula, pneumothorax), catheter manipulation (e.g., valvular damage, microemboli, perforation of the coronary sinus or myocardial wall, coronary artery dissection, thrombosis), or delivery of radiofrequency (RF) energy (e.g., AV block, myocardial perforation, coronary artery spasm or occlusion, transient ischemic attacks, cerebrovascular accidents). The procedure-related mortality reported for catheter ablation of accessory pathways ranges from 0 to 0.2%. The voluntary Multicentre European Radiofrequency Survey (MERFS) reported data from 2222 patients who underwent catheter ablation of an accessory pathway. The overall complication rate was 4.4%, including 3 deaths (0.13%). The 1995 NASPE survey of 5427 patients who underwent catheter ablation of an accessory pathway reported a total of 99 (1.82%) significant complications, including 4 procedure-related deaths (0.08%). Among the 500 patients who underwent catheter ablation of an accessory pathway as part of a prospective, multicenter clinical trial, there was 1 death (0.2%). This patient died of dissection of the left main coronary artery during an attempt at catheter ablation of a left free-wall accessory pathway. The most common major complications are complete AV block and cardiac tamponade. The incidence of inadvertent complete AV block ranges from 0.17 to 1.0%. Most occur in the setting of attempted ablation of septal accessory pathways located close to the AV junction. The frequency of cardiac tamponade varies between 0.13 and 1.1%.

Subgroups Most Likely to Experience Harms

• Patients with structural heart defects may not be candidates for catheter ablation.
• Ibutilide should not be used in patients with an ejection fraction of less than 30% due to increased risk of polymorphic ventricular tachycardia (VT). Intravenous ibutilide should not be taken by patients with severe structural cardiac diseases or prolonged QT interval, or in those with underlying sinus node disease.
• Patients with kidney or liver disease are at increased risk of drug toxicity, including proarrhythmia with antiarrhythmic drugs.

• Class Ic agents (i.e., flecainide and propafenone) are contraindicated for patients with structural heart disease.
• Flecainide and propafenone are relatively contraindicated for patients with coronary artery disease, left ventricular dysfunction, or other significant heart disease.
• Beta blockers and sotalol are often contraindicated in patients with multifocal atrial tachycardia (MAT) due to pulmonary disease.
• Contraindications for dofetilide include a creatinine clearance less than 20, hypokalemia, hypomagnesemia, and prolonged QT at baseline.

• These guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment regarding care of a particular patient must be made by the physician and the patient in light of all of the circumstances presented by that patient. There are circumstances in which deviations from these guidelines are appropriate.
• The guideline is a consensus document that includes evidence and expert opinions from several countries. The pharmacologic and nonpharmacologic antiarrhythmic approaches discussed may, therefore, include some drugs and devices that do not have the approval of governmental regulatory agencies.

An implementation strategy was not provided.

Living with Illness

Effectiveness

• Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ, Campbell WB, Haines DE, Kuck KH, Lerman BB, Miller DD, Shaeffer CW, Stevenson WG, Tomaselli GF. 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 and the European Society of Cardiology Committee for Practice Guidelines. Bethesda (MD): American College of Cardiology Foundation; 2003. 62 p. [537 references]

Not applicable: The guideline was not adapted from another source.

2003

American College of Cardiology Foundation - Medical Specialty Society
American Heart Association - Professional Association
European Society of Cardiology - Medical Specialty Society

The American College of Cardiology and the American Heart Association. No outside funding accepted.

Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias

Committee Members: Carina Blomstrom-Lundqvist, MD, PhD, FACC, FESC (Co-Chair); Melvin M. Scheinman, MD, FACC, (Co-Chair) Etienne M. Aliot, MD, FACC, FESC; Joseph S. Alpert, MD, FACC, FAHA, FESC; Hugh Calkins, MD, FACC, FAHA; A. John Camm, MD, FACC, FAHA, FESC; W. Barton Campbell, MD, FACC, FAHA; David E. Haines, MD, FACC; Karl H. Kuck, MD, FACC, FESC; Bruce B. Lerman, MD, FACC; D. Douglas Miller, MD, CM, FACC; Charlie Willard Shaeffer, Jr., MD, FACC; William G. Stevenson, MD, FACC; Gordon F. Tomaselli, MD, FACC, FAHA

Task Force Members: Elliott M. Antman, MD, FACC, FAHA, (Chair); Sidney C. Smith, Jr., MD, FACC, FAHA, FESC (Vice Chair); Joseph S. Alpert, MD, FACC, FAHA, FESC; David P. Faxon, MD, FACC, FAHA; Valentin Fuster, MD, PhD, FACC, FAHA, FESC; Raymond J. Gibbons, MD, FACC, FAHA*#; Gabriel Gregoratos, MD, FACC, FAHA; Loren F. Hiratzka, MD, FACC, FAHA; Sharon Ann Hunt, MD, FACC, FAHA; Alice K. Jacobs, MD, FACC, FAHA; Richard O. Russell, Jr., MD, FACC, FAHA*

ESC Committee for Practice Guidelines Members: Silvia G. Priori, MD, PhD, FESC (Chair); Jean-Jacques Blanc, MD, PhD, FESC; Andzrej Budaj, MD, FESC; Enrique Fernandez Burgos, MD; Martin Cowie, MD, PhD, FESC; Jaap Willem Deckers, MD, PhD, FESC; Maria Angeles Alonso Garcia, MD, FESC; Werner W. Klein, MD, FACC, FESC#; John Lekakis, MD, FESC; Bertil Lindahl, MD; Gianfranco Mazzotta, MD, FESC; Joao Carlos Araujo Morais, MD, FESC; Ali Oto, MD, FACC, FESC; Otto Smiseth, MD, PhD, FESC; Hans-Joachim Trappe, MD, PhD, FESC

*Former Task Force Member
#Immediate Past Chair

The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines and the European Society of Cardiology (ESC) Committee on Practice Guidelines make every effort to avoid any actual or potential conflict of interest that might arise as a result of an industry relationship or from personal biases of the writing panel. Specifically, all members of the writing panel were asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest. These statements are reported orally to all members of the writing panel during the first meeting and are updated as changes occur.

This is the current release of the guideline.

None available

This summary was completed by ECRI on March 11, 2004. The information was verified by the guideline developer on May 9, 2005.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions as follows:

Copyright to the original guideline is owned by the American College of Cardiology Foundation (ACCF), the American Heart Association, Inc. (AHA), and the European Society of Cardiology (ESC). NGC users are free to download a single copy for personal use. Reproduction without permission of the ACC/AHA guidelines is prohibited. Permissions requests should be directed to Patty Jones, 9111 Old Georgetown Rd, Bethesda, MD 20814-1699; telephone, (301) 493-2368; fax, (301) 897-9745.