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1.
Page  RL, Joglar  JA, Al-Khatib  SM,  et al.  2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia—executive summary. J Am Coll Cardiol. 2016;67:1575-1623.PubMedArticle
2.
Blomström-Lundqvist  C, Scheinman  MM, Aliot  EM,  et al; European Society of Cardiology Committee, NASPE-Heart Rhythm Society.  ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias—executive summary. J Am Coll Cardiol. 2003;42(8):1493-1531.PubMedArticle
3.
Jacobs  AK, Anderson  JL, Halperin  JL.  The evolution and future of ACC/AHA clinical practice guidelines. J Am Coll Cardiol. 2014;64(13):1373-1384.PubMedArticle
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JAMA Cardiology Clinical Guidelines Synopsis
December 28, 2016

Ongoing Management of Patients With Supraventricular Tachycardia

Author Affiliations
  • 1Division of Cardiology and Duke Clinical Research Institute, Duke University Hospital, Durham, North Carolina
  • 2Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison
JAMA Cardiol. Published online December 28, 2016. doi:10.1001/jamacardio.2016.5085
Box Section Ref ID

Guideline title 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia

Developer ACC/AHA/HRS

Release dates September 23, 2015 (online); April 5, 2016 (print)

Prior version October 14, 2003

Funding source ACC/AHA/HRS

Target population Adults with SVT

Major recommendations

  • This guideline presents recommendations for the management of SVT. Consistent with previous guidelines, the document does not include AF. This synopsis focuses on recommendations for the ongoing management of SVT.

  • In patients with symptomatic SVT (in the absence of ventricular preexcitation during sinus rhythm), chronic use of oral β blockers, diltiazem, or verapamil is useful (moderate-quality evidence).

  • Flecainide and propafenone are reasonably effective (moderate-quality evidence) as a second-line therapy in patients without structural or ischemic heart disease when ablation is not an option, is not preferred by the patient, or is unsuccessful.

  • In patients with inappropriate sinus tachycardia, ongoing treatment with ivabradine can be effective (moderate-quality evidence). As ivabradine is newly approved this is a new recommendation.

  • Chronic treatment with oral verapamil (moderate-quality evidence), diltiazem (low-quality evidence), or metoprolol (low-quality evidence) is reasonably effective for patients with recurrent symptomatic multifocal atrial tachycardia.

  • Catheter ablation of the slow pathway is recommended (moderate-quality evidence) in patients with AVNRT. If ablation is not appropriate or preferred by the patient, then oral verapamil, diltiazem, or a β blocker is recommended (moderate quality evidence).

  • Flecainide or propafenone are also reasonably effective (moderate-quality evidence) for the ongoing management of patients with AVNRT who have no structural or ischemic heart disease.

  • Catheter ablation of the accessory pathway is recommended (moderate-quality evidence) for patients with AVRT and/or pre-excited AF. If catheter ablation is not appropriate or preferred by the patient, an oral β blocker, diltiazem, or verapamil is indicated (low-quality evidence) when pre-excitation is not present on the resting ECG.

  • Flecainide or propafenone are also reasonably effective (moderate-quality evidence) for patients with AVRT who have no structural or ischemic heart disease.

  • Catheter ablation of the cavotricuspid isthmus is effective (moderate-quality evidence) for patients with an atrial flutter that is either symptomatic or difficult to rate-control.

  • A β blocker, diltiazem, or verapamil is effective (low-quality evidence) in controlling the ventricular rate in patients with hemodynamically-tolerated atrial flutter.

  • In patients with symptomatic, recurrent atrial flutter, amiodarone, dofetilide, and sotalol can be effective with the medication choice depending on the presence of heart disease and comorbidities.

Abbreviations: ACC, American College of Cardiology; AF, atrial fibrillation; AHA, American Heart Association; AVNRT, atrioventricular nodal tachycardia; AVRT, atrioventricular reentrant tachycardia; ECG, electrocardiogram; HRS, Heart Rhythm Society; SVT, supraventricular tachycardia.

Summary of the Clinical Problem

Supraventricular tachycardia (SVT) is frequently encountered by health care clinicans.1,2 Therefore, it is imperative for clinicians to recognize the clinical manifestations of SVT and choose the best test to establish a diagnosis. Available tests include a Holter monitor (if symptoms occur daily or every other day), ambulatory electrocardiographic monitoring (if symptoms occur weekly or biweekly), or an implantable loop recorder (if symptoms are infrequent or a diagnosis could not be established with noninvasive monitoring despite ongoing symptoms). Long-term management of SVT includes pharmacologic therapy, catheter ablation, or observation. The selection of long-term treatment depends on several factors, including the frequency and severity of the patient’s symptoms, the presence of structural heart disease, the presence of noncardiac comorbidities, and the patient’s preferences.1,2

Characteristics of the Guideline Source

This guideline was developed by the American College of Cardiology, the American Heart Association, and the Heart Rhythm Society.1 The guideline writing committee was composed of 17 members: 14 adult electrophysiologists, 1 pediatric electrophysiologist, 1 general cardiologist, and 1 patient/consumer representative. Recommendations were developed based on available evidence with literature searches focusing on randomized controlled trials (RCTs), registries, nonrandomized comparative and descriptive studies, and systematic reviews.

Evidence Base

The recommendations for long-term management of patients with SVT covered the following: observation of patients who are minimally symptomatic; the need to exclude reversible causes for SVT; pharmacologic treatment with a β-blocker, a calcium channel blocker, digoxin, an antiarrhythmic medication, ivabradine, and an antithrombotic medication for patients with atrial flutter; catheter ablation; surgical ablation or repair of a congenital abnormality; and atrial pacing. A literature review was conducted through September 2014. To be reviewed, studies had to involve human participants, be published in English, and be indexed in MEDLINE (through PubMed), EMBASE, the Cochrane Library, or the Agency for Healthcare Research and Quality. Studies resulting from the literature search were systematically reviewed.

Of 60 classes of recommendation involving the ongoing management of SVT, 15 were class I, 20 class IIa, 23 class IIb, and 2 class III. Of the 15 class I recommendations, 0 were level A, 4 were B-R, 5 were B-NR, 6 were C, and 0 were E. Only 15 of the 60 recommendations for ongoing management of SVT were supported by moderate-quality evidence from at least 1 RCT. None were supported by high-quality evidence.

Benefits and Harms

The guideline writing committee considered the potential benefits and harms of each intervention. β-blockers and calcium channel blockers are generally safe and well-tolerated in the absence of contraindications such as bradycardia, hypotension, and, in the case of calcium channel blockers, significant left ventricular dysfunction. Except for the recommendation on the potential use of digoxin for pregnant patients with highly symptomatic SVT, all recommendations involving digoxin were class IIb, reflecting the lack of effectiveness of digoxin for most SVT types and the nontrivial risk of toxicity. Antiarrhythmic medications (other than β-blockers and calcium channel blockers) can be used for SVT; however, given their toxicity profile and the potential for curing many SVTs with catheter ablation, these medications are generally not used as first-line therapy unless preferred by the patient. Assessing the need for antithrombotic medication in patients with atrial flutter should mirror that for atrial fibrillation. Catheter ablation performed by an experienced operator is curative for most patients with an SVT and is the preferred strategy for many patients. The current guideline included 14 recommendations on catheter ablation; 6 were with class I, 5 with class IIa, and 3 with class IIb. Recommendations identified harm in using oral digoxin for ongoing management of patients with atrioventricular reciprocating tachycardia or atrial fibrillation and pre-excitation on a resting electrocardiogram and the use of flecainide for SVT among adults congenital heart disease and significant ventricular dysfunction.

Discussion

Although high-quality evidence was not available for any of the recommendations, many recommendations are supported by moderate-quality evidence that should inform clinical decision making. Based on small trials and longstanding experience, most of the interventions covered by this guideline are standard, and it is unlikely that these interventions will be examined in large RCTs. However, new antiarrhythmic medications, ablation catheters, and techniques will emerge. Such therapies should be studied in well-designed and well-conducted RCTs.

Areas in Need of Future Study or Ongoing Research

For SVTs that are difficult to cure with catheter ablation, it is important to develop new antiarrhythmic medications with better efficacy and fewer adverse effects. Also, newer ablation catheters and techniques may improve the effectiveness of catheter ablation for all types of SVT while minimizing risk. It is important to elucidate the best treatment approaches for certain subgroups of patients with SVT, such as older patients and patients with multiple comorbidities. Future studies should examine the effect of different interventions on the patient’s quality of life and the cost implications of different interventions.

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Article Information

Corresponding Author: Sana M. Al-Khatib, MD, MHS, Duke Clinical Research Institute, 2400 Pratt St, Durham, NC 27705 (sana.alkhatib@duke.edu).

Published Online: December 28, 2016. doi:10.1001/jamacardio.2016.5085.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

References
1.
Page  RL, Joglar  JA, Al-Khatib  SM,  et al.  2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia—executive summary. J Am Coll Cardiol. 2016;67:1575-1623.PubMedArticle
2.
Blomström-Lundqvist  C, Scheinman  MM, Aliot  EM,  et al; European Society of Cardiology Committee, NASPE-Heart Rhythm Society.  ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias—executive summary. J Am Coll Cardiol. 2003;42(8):1493-1531.PubMedArticle
3.
Jacobs  AK, Anderson  JL, Halperin  JL.  The evolution and future of ACC/AHA clinical practice guidelines. J Am Coll Cardiol. 2014;64(13):1373-1384.PubMedArticle
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