SVT Guideline Update

2015 ACC/AHA/HRS Guideline for the Management

of Adult Patients With Supraventricular Tachycardia

Richard L. Page, MD, FAHA, FACC, FHRS

University of Wisconsin
School of Medicine and Public Health

Developed in Partnership with the Heart Rhythm Society

© American College of Cardiology Foundation and American Heart Association

 2015 ACC/AHA/HRS SVT Guideline Writing Committee

Richard L. Page, MD, FACC, FAHA, FHRS, Chair

José A. Joglar, MD, FACC, FAHA, FHRS, Vice Chair

Mary A. Caldwell, RN, MBA, PhD, FAHA Stephen C. Hammill, MD, FACC, FHRS‡
Hugh Calkins, MD, FACC, FAHA, FHRS*‡ Julia H. Indik, MD, PhD, FACC, FAHA,
Jamie B. Conti, MD, FACC*†§ FHRS‡
Bruce D. Lindsay, MD, FACC, FHRS*‡
Barbara J. Deal, MD†
Brian Olshansky, MD, FACC, FAHA, FHRS*†
N.A. Mark Estes III, MD, FACC, FAHA,
FHRS*† Andrea M. Russo, MD, FACC, FHRS*§
Michael E. Field, MD, FACC, FHRS† Win-Kuang Shen, MD, FACC, FAHA, FHRS║
Zachary D. Goldberger, MD, MS, FACC, Cynthia M. Tracy, MD, FACC†
FAHA, FHRS†
Sana M. Al-Khatib, MD, MHS, FACC, FAHA, FHRS, Evidence Review Committee
Chair†
†ACC/AHA Representative. ‡HRS Representative. §ACC/AHA Task Force on Performance Measures Liaison.
║ACC/AHA Task Force on Clinical Practice Guidelines Liaison.
 Scope of the Guideline

• Supersedes the “2003 ACC/AHA/ESC Guideline for the

Management of Patients with Supraventricular Arrhythmias”
• Addresses regular as well as irregular SVT (such as atrial flutter
with irregular ventricular response and multifocal atrial
tachycardia) but does not include atrial fibrillation
• Aimed at the adult population (>18 years of age) and gives no
specific recommendations for pediatric patients
• Emphasizes shared decision making with the patient whenever
possible
 Highlights of the Guideline

• New recommendations for use of ivabradine in patients with

inappropriate sinus tachycardia.

• New recommendations for the management of patient with

asymptomatic Wolff Parkinson White pattern, based on a
systematic review of the evidence.

• Ablation techniques have improved, including techniques to

minimize radiation exposure. As such, catheter ablation may
be reasonable in pregnant patients with efforts toward
minimizing radiation exposure.
Systematic Review

Acute Treatment
 Table 1. Applying
Class of
Recommendation and
Level of Evidence
Acute Treatment of Regular SVT of Unknown Mechanism
Regular SVT

Vagal maneuvers
and/or IV adenosine
(Class I)

If ineffective
or not feasible

Hemodynamically
stable

Yes No

IV beta blockers, Synchronized

IV diltiazem, or cardioversion*
IV verapamil (Class I)
(Class IIa)

If ineffective or not feasible

Colors correspond to Class of Recommendation in
Table 1; drugs listed alphabetically.
Synchronized *For rhythms that break or recur spontaneously,
cardioversion* synchronized cardioversion is not appropriate.
(Class I) IV indicates intravenous; and SVT, supraventricular
tachycardia.
Ongoing Management of SVT of Unknown Mechanism
Regular SVT

Pre-excitation
present in
sinus rhythm

Yes No

Ablation
Ablation
candidate, willing
candidate, pt prefers Colors correspond to
to undergo
ablation Class of Recommendation
ablation
in Table 1; drugs listed
alphabetically.
Yes No No Yes
*Clinical follow-up without
treatment is also an
option.
EP study and If EP study and EP indicates
catheter ablation Medical therapy* If catheter ablation
ineffective electrophysiological; pt,
(Class I) ineffective (Class I)
patient; SHD, structural
heart disease (including
Drug options ischemic heart disease);
SVT, supraventricular
Beta blockers, tachycardia; and VT,
Flecainide or Amiodarone, Digoxin ventricular tachycardia.
diltiazem, or verapamil,
propafenone dofetilide, (in the absence of
(in the absence of
(in the absence of SHD) or sotalol pre-excitation)
pre-excitation)
(Class IIa) (Class IIb) (Class IIb)
(Class I)
Inappropriate Sinus Tachyarrhythmias – Ongoing
Management
COR LOE Recommendations

Evaluation for and treatment of reversible

I C-LD causes are recommended in patients with
suspected IST.
Ivabradine is reasonable for ongoing
IIa B-R management in patients with symptomatic IST.

Beta blockers may be considered for ongoing

IIb C-LD management in patients with symptomatic IST.

The combination of beta blockers and

IIb C-LD ivabradine may be considered for ongoing
management in patients with IST.
Manifest and Concealed Accessory Pathways

Management of Asymptomatic
Pre-Excitation
 Asymptomatic Patients With Pre-Excitation

COR LOE Recommendations

In asymptomatic patients with pre-excitation, the findings

of abrupt loss of conduction over a manifest pathway
B-NRSR
during exercise testing in sinus rhythm (Level of
I Evidence: B-NR) SR or intermittent loss of pre-excitation
during ECG or ambulatory monitoring (Level of Evidence:
C-LDSR C-LD) SR are useful to identify patients at low risk of rapid
conduction over the pathway.
An EP study is reasonable in asymptomatic patients with
IIa B-NRSR pre-excitation to risk-stratify for arrhythmic events.

Catheter ablation of the accessory pathway is reasonable

in asymptomatic patients with pre-excitation if an EP
IIa B-NRSR study identifies a high risk of arrhythmic events, including
rapidly conducting pre-excited AF.
Asymptomatic Patients With Pre-Excitation (cont’d)

COR LOE Recommendations

Catheter ablation of the accessory pathway is reasonable

in asymptomatic patients if the presence of pre-excitation
IIa B-NRSR precludes specific employment (such as with pilots).

Observation, without further evaluation or treatment, is

reasonable in asymptomatic patients with pre-excitation.
IIa B-NRSR
 Manifest and Concealed Accessory Pathways

Risk Stratification of Symptomatic Patients With

Manifest Accessory Pathways
 Risk Stratification of Symptomatic Patients With
Manifest Accessory Pathways

COR LOE Recommendations

In symptomatic patients with pre-excitation, the

B-NR findings of abrupt loss of conduction over the
pathway during exercise testing in sinus rhythm
(Level of Evidence: B-NR) or intermittent loss of pre-
I
excitation during ECG or ambulatory monitoring
C-LD (Level of Evidence: C-LD) are useful for identifying
patients at low risk of developing rapid conduction
over the pathway.
An EP study is useful in symptomatic patients with
I B-NR pre-excitation to risk-stratify for life-threatening
arrhythmic events.
 2015 ACC/AHA/HRS SVT Guideline

Special Populations:

• Patients With Adult Congenital Heart Disease

• Pregnancy

• SVT in Older Populations

 Pregnancy – Acute Treatment

COR LOE Recommendations

Vagal maneuvers are recommended for acute

I C-LD treatment in pregnant patients with SVT.
Adenosine is recommended for acute treatment in
I C-LD pregnant patients with SVT.
Synchronized cardioversion is recommended for
acute treatment in pregnant patients with
I C-LD hemodynamically unstable SVT when
pharmacological therapy is ineffective or
contraindicated.
Intravenous metoprolol or propranolol is reasonable
IIa C-LD for acute treatment in pregnant patients with SVT
when adenosine is ineffective or contraindicated.
 Pregnancy – Acute Treatment (cont’d)

COR LOE Recommendations

Intravenous verapamil may be reasonable for acute

treatment in pregnant patients with SVT when
IIb C-LD
adenosine and beta blockers are ineffective or
contraindicated.
Intravenous procainamide may be reasonable for
acute treatment in pregnant patients with SVT when
IIb C-LD
adenosine and beta blockers are ineffective or
contraindicated.
Intravenous amiodarone may be considered for
acute treatment in pregnant patients with potentially
IIb C-LD
life-threatening SVT when other therapies are
ineffective or contraindicated.
 Pregnancy – Ongoing Management
COR LOE Recommendations

The following drugs, alone or in combination, can be effective

for ongoing management in pregnant patients with highly
symptomatic SVT:
a. Digoxin
b. Flecainide
IIa C-LD
c. Metoprolol
d. Propafenone
e. Propranolol
f. Sotalol
g. Verapamil
Catheter ablation may be reasonable in pregnant patients
IIb C-LD with highly symptomatic, recurrent, drug-refractory SVT with
efforts toward minimizing radiation exposure.
Oral amiodarone may be considered for ongoing
management in pregnant patients when treatment of highly
IIb C-LD symptomatic, recurrent SVT is required and other therapies
are ineffective or contraindicated.
 Special Populations

SVT in Older Populations

COR LOE Recommendation

Diagnostic and therapeutic approaches to SVT

should be individualized in patients more than 75
I B-NR years of age to incorporate age, comorbid illness,
physical and cognitive functions, patient
preferences, and severity of symptoms.
Thank you