Executive Summary: European Heart Rhythm Association Consensus Document on the Management of Supraventricular Arrhythmias

Demosthenes G Katritsis
Giuseppe Boriani
Francisco G Cosio
Pierre Jaïs
Gerhard Hindricks
Mark E Josephson
Roberto Keegan
Bradley P Knight
Karl-Heinz Kuck
Deirdre A Lane
Gregory YH Lip
Helena Malmborg
Hakan Oral
Carlo Pappone
Sakis Themistoclakis
Kathryn A. Wood
Kim Young-Hoon
Carina Blomström-Lundqvist
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Abstract

This paper is an executive summary of the full European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, published in Europace. It summarises developments in the field and provides recommendations for patient management, with particular emphasis on new advances since the previous European Society of Cardiology guidelines. The EHRA consensus document is available to read in full at http://europace.oxfordjournals.org

Keywords
Supraventricular tachycardia, supraventricular arrhythmias, EHRA consensus
Received date
20 October 2016
Accepted date
20 October 2016
Citation
Arrhythmia & Electrophysiology Review 2016;5(3):210–4.
DOI
https://doi.org/10.15420/aer.2016:5.3.GL1
Acknowledgement
This article is an abbreviated version of the full consensus document published in Europace DOI: 10.1093/europace/euw301. ©ESC 2016.

Endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE)

This is an executive summary of the full consensus document on the management of supraventricular tachycardia (SVT) patients published in Europace. The consensus document was prepared by a Task Force from the European Heart Rhythm Association (EHRA) with representation from the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE). It summarises current developments in the field and provides recommendations for the management of patients with SVT based on the principles of evidence-based medicine, with focus on new advances since the last ESC guidelines.1 It does not cover atrial fibrillation, which is the subject of a separate clinical guideline.

The process for evidence review has been described in the full document. Consensus statements are evidence-based, and derived primarily from published data. Current systems of ranking level of evidence are becoming complicated in a way that their practical utility might be compromised. We have, therefore, opted for an easier and, perhaps, more user-friendly system of ranking that should allow physicians to easily assess current status of evidence and consequent guidance (see Table 1). EHRA grading of consensus statements does not have separate definitions of Level of Evidence.

Diagnosis and Management of SVT

The term supraventricular tachycardia literally indicates tachycardias (atrial and/or ventricular rates >100 bpm at rest), the mechanism of which involves tissue from the His bundle or above (see Table 2). Traditionally, however, SVT has been used to describe all kinds of tachycardias apart from ventricular tachycardias and atrial fibrillation (AF), the mechanisms of which are illustrated in Figure 1. The term narrow-QRS tachycardia indicates those with a QRS duration ≤ 120 ms. A wide-QRS tachycardia refers to one with a QRS duration >120 ms (see Table 3). In clinical practice, SVT may present as narrow- or wide-QRS tachycardias, and most of them usually, although not invariably, manifest as regular rhythms.

Recommendations for the differential diagnosis of various forms of supraventricular tachycardias, as well as supporting references, are included in Figures 2–6. Recommendations for acute treatment preferences are given. Long-term treatment with antiarrhythmic drugs and/or catheter ablation are also presented and described for each type of SVT, with detailed recommendations given in Figure 7 and Tables 4–15. As compared with the previous SVT guideline from 2003, this consensus document contains several new recommendations based on new trials and meta-analyses, such as the management of patients with asymptomatic Wolff-Parkinson-White syndrome, and the cautious use of certain antiarrhythmic drugs in adult congenital heart diseases. Some discrepancies with the corresponding American College of Cardiology/American Heart Association/Heart Rhythm Society guidelines of 20152 may be related to new evidence that has emerged as well as differences in interpretation of studies and experts’ opinion.

Table 1: Scientific Rationale of Recommendations

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Table 2: Conventional Classification of Supraventricular Tachycardias

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Table 3: Differential Diagnosis of Narrow and Wide QRS Tachycardias

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Table 4: Acute Management of SVT without Established Diagnosis

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Table 5: Therapy of Sinus Tachycardia

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Table 6: Therapy of Focal Atrial Tachycardia

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Table 7: Therapy of Multifocal Atrial Tachycardia

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Table 8: Therapy of Atrial Flutter/ Macro-reentrant Tachycardia

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Table 9: Therapy of Atrioventricular Nodal Reentrant Tachycardia

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Table 10: Therapy of Focal Junctional Tachycardia

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Table 11: Therapy of Atrioventricular Reentrant Tachycardias Due to Manifest or Concealed Accessory Pathways

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Table 12: Management of Asymptomatic Pre-excitation

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Table 13: Acute Therapy of Supraventricular Tachycardias in Adult Congenital Heart Disease Patients

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Table 14: Chronic Therapy of Supraventricular Tachycardias in Adult Congenital Heart Disease Patients

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Table 15: Recommendations for Treatment of Supraventricular Tachycardias During Pregnancy

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Figure 1: Tachycardia Circuit and Typical 12-lead ECGs in Different Types of Narrow- and Wide-QRS Supraventricular Tachycardias

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Figure 2: Differential Diagnosis of Narrow-QRS Tachycardia

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Figure 3: Responses of Narrow Complex Tachycardias to Adenosine

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Figure 4: Differential Diagnosis of Wide QRS using the Brugada et al. Algorithm

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Figure 5: Differential Diagnosis of Wide-QRS Tachycardia using the Vereckei et al. Algorithm

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Figure 6: Measurement of the R-wave Peak Time (RWPT) in Lead II

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Figure 7: Acute Treatment of Regular Tachycardia

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