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

BySteven Lome, MD

Year released: 2015

Societies: American College of Cardiology (ACC), American Heart Association (AHA), Heart Rhythm Society (HRS)

Summary

The ACC, AHA and HRS made evidence-based recommendations for the management of adults with all types of supraventricular tachycardia (SVT), excluding atrial fibrillation (AF).

The committee wrote that although AF is considered an SVT, the term SVT typically does not refer to AF. The 2014 ACC/AHA/HRS Guideline for the Management of Atrial Fibrillation addresses how to better assess and treat that patient population.

This guideline addresses other SVTs, including regular narrow-QRS complex tachycardias, as well as atrial flutter with irregular ventricular response and multifocal atrial tachycardia.

The updated guideline incorporates new and existing knowledge derived from published clinical trials, basic science and comprehensive review articles, along with evolving treatment strategies and new drugs, according to the writing committee. This guideline replaces the 2003 ACC/AHA/European Society of Cardiology (ESC) Guidelines for the Management of Patients With Supraventricular Arrhythmias.

Some recommendations from previous guidelines — including the 2003 guidelines — have either been eliminated or updated as warranted by new evidence or a better understanding of earlier evidence.

Acute treatment

The committee highlights that approximately 50,000 emergency department (ED) visits each year are attributed to patients with SVT. Because of this, emergency physicians may be the first to evaluate patients whose tachycardia mechanism is unknown, and they have the opportunity to diagnose the mechanism of arrhythmia.

It is important to record a 12-lead electrocardiogram (ECG) to differentiate tachycardia mechanisms according to whether the atrioventricular (AV) node is an obligate component because treatment that targets the AV node will not reliably terminate tachycardias that are not AV node dependent, according to the committee. Additionally, the committee wrote that if the QRS duration is greater than 120 ms, it is crucial to distinguish VT from SVT with aberrant conduction, pre-existing bundle-branch block or pre-excitation.

The panel placed recommendations into various classes to help identify the strength of each recommendation. Anything labeled as class I was considered strong, recommended and should be performed or administered. Anything labeled class III had no benefit or the risk outweighs the benefit.

A class I recommendation suggests that adenosine is recommended for acute treatment in patients with regular SVT.

Vagal maneuvers are recommended for acute treatment in patients with regular SVT, according to the committee.

An additional class I recommendation indicates that synchronized cardioversion is recommended for acute treatment in patients with hemodynamically unstable SVT when vagal maneuvers or adenosine are ineffective or not feasible.

Ongoing management

The committee recommends that 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.

Additionally, the committee recommends electrophysiological (EP) testing with the option of ablation is useful for the diagnosis and potential treatment of SVT.

The committee made several recommendations that are classified as class IIb, which states the benefit is greater or equal to the risk. One of those recommendations was that 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 are ineffective or contraindicated.