New guideline advises diagnoses, referrals, treatments for supraventricular tachycardia

Three medical societies released a guideline aimed at helping inpatient and outpatient clinicians treat patients with supraventricular tachycardia (SVT) other than atrial fibrillation.

The guideline was a collaboration of the American College of Cardiology, American Heart Association, and Heart Rhythm Society. The overall goal of the guideline is to provide clinicians with the tools needed to successfully diagnose and treat patients with SVT other than atrial fibrillation, including regular narrow–QRS complex tachycardias or irregular ones such as atrial flutter with irregular ventricular response and multifocal atrial tachycardia. It includes tools for quick diagnosis, referrals to cardiology and electrophysiology specialists, discussion and collaboration with the patient, and prescription of appropriate treatment.

The guideline also aims to aid clinicians to help patients differentiate between SVT and other disorders, such as panic attack and chest pain, as well as shortness of breath and syncope or near syncope, which may cause similar symptoms. Among the many recommendations are ones focused on acute treatment and ongoing management.

Acute treatment:

• Vagal maneuvers are recommended for acute treatment in patients with regular SVT (class of recommendation, 1; level of evidence, B-randomized);
• Adenosine is recommended for acute treatment in patients with regular SVT (class of recommendation, 1; level of evidence, B-randomized);
• Synchronized cardioversion is recommended for acute treatment in patients with hemodynamically unstable SVT when vagal maneuvers or adenosine are ineffective or not feasible (class of recommendation, 1; level of evidence, B-nonrandomized);
• Synchronized cardioversion is recommended for acute treatment in patients with hemodynamically stable SVT when pharmacological therapy is ineffective or contraindicated (class of recommendation, 1; level of evidence, B-nonrandomized);
• Intravenous diltiazem or verapamil can be effective for acute treatment in patients with hemodynamically stable SVT (class of recommendation, 2a; level of evidence, B-randomized); and
• Intravenous beta-blockers are reasonable for acute treatment in patients with hemodynamically stable SVT (class of recommendation, 2a; level of evidence, C-limited evidence).

Ongoing management:

• Oral beta-blockers, diltiazem, or verapamil is useful for ongoing management in patients with symptomatic SVT who do not have ventricular pre-excitation during sinus rhythm (class of recommendation, 1; level of evidence, B-randomized);
• Electrophysiological study with the option of ablation is useful for the diagnosis and potential treatment of SVT (class of recommendation, 1; level of evidence, B-nonrandomized);
• Patients with SVT should be educated on how to perform vagal maneuvers for ongoing management of SVT (class of recommendation, 1; level of evidence, C-limited data);
• Flecainide or propafenone is reasonable for ongoing management in patients without structural heart disease or ischemic heart disease who have symptomatic SVT and are not candidates for, or prefer not to undergo, catheter ablation (class of recommendation, 2; level of evidence, B-randomized);
• Sotalol may be reasonable for ongoing management in patients with symptomatic SVT who are not candidates for, or prefer not to undergo, catheter ablation (class of recommendation, 2b; level of evidence, B-randomized);
• Dofetilide may be reasonable for ongoing management in patients with symptomatic SVT who are not candidates for, or prefer not to undergo, catheter ablation and in whom beta-blockers, diltiazem, flecainide, propafenone, or verapamil is ineffective or contraindicated (class of recommendation, 2b; level of evidence, B-randomized);
• Oral amiodarone may be considered for ongoing management in patients with symptomatic SVT who are not candidates for, or prefer not to undergo, catheter ablation and in whom beta-blockers, diltiazem, dofetilide, flecainide, propafenone, sotalol, or verapamil is ineffective or contraindicated (class of recommendation, 2b; level of evidence, C-limited data); and
• Oral digoxin may be reasonable for ongoing management in patients with symptomatic SVT without pre-excitation who are not candidates for, or prefer not to undergo, catheter ablation (class of recommendation, 2b; level of evidence, B-randomized);

This guideline supersedes the organizations' 2003 guidelines on management of patients with supraventricular arrhythmias. It was jointly published Sept. 23 in the Journal of the American College of Cardiology, Circulation, and HeartRhythm.