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## Complete Summary

#### GUIDELINE TITLE

ACC/AHA/ESC guidelines for the management of patients with
supraventricular arrhythmias. A report of the American College of
Cardiology/American Heart Association Task Force and the European
Society of Cardiology Committee for Practice Guidelines (Writing
Committee to Develop Guidelines for the Management of Patients with
Supraventricular Arrhythmias).

#### BIBLIOGRAPHIC SOURCE(S)

Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H,
Camm AJ, Campbell WB, Haines DE, Kuck KH, Lerman BB, Miller DD, Shaeffer
CW, Stevenson WG, Tomaselli GF. ACC/AHA/ESC guidelines for the
management of patients with supraventricular arrhythmias. A report of
the American College of Cardiology/American Heart Association Task Force
and the European Society of Cardiology Committee for Practice
Guidelines. Bethesda (MD): American College of Cardiology Foundation;
2003. 62 p. \[537 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Supraventricular arrhythmias

#### GUIDELINE CATEGORY

Assessment of Therapeutic Effectiveness\
Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Cardiology\
Family Practice\
Internal Medicine\
Obstetrics and Gynecology

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

-   To assist physicians in clinical decision making by describing a
    range of generally acceptable approaches for the diagnosis and
    management of supraventricular arrhythmias.

-   To provide clinicians with practical and authoritative guidelines
    for the management and treatment of patients with supraventricular
    arrhythmias by providing recommendations for diagnostic procedures
    as well as indications for antiarrhythmic drugs and/or
    nonpharmacologic treatments.

#### TARGET POPULATION

Patients with supraventricular arrhythmias including rhythms emanating
from the sinus node, from atrial tissue (atrial flutter), and from
junctional as well as reciprocating or accessory pathway-mediated
tachycardia

**Note**: Patients with atrial fibrillation and pediatric patients are
not covered. Postural orthostatic tachycardia syndrome is not included
because it is not a disorder of the sinus node.

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation**

1.  Clinical history

2.  Physical examination

**Diagnosis**

1.  12-lead electrocardiogram (ECG)

2.  Echocardiographic examination

3.  24-hour Holter

4.  Exercise testing

5.  Transesophageal atrial recording and stimulation

**Management**

1.  Patient education

    -   Elimination of precipitating factors such as caffeine, alcohol,
        nicotine, recreational drugs, or hyperthyroidism

    -   Vagal maneuvers

2.  Pharmacologic treatment

    -   Adenosine

    -   Digoxin

    -   Beta-blocking agents (e.g., metoprolol)

    -   Nondihydropyridine calcium-channel antagonists (e.g., diltiazem,
        verapamil)

    -   Class Ic drugs (e.g., flecainide, propafenone)

    -   Class III drugs (e.g., sotalol, amiodarone, dofetilide)

    -   Class Ia drugs (e.g., quinidine, procainamide, disopyramide)

3.  Direct current (DC) cardioversion

4.  Atrial overdrive pacing

5.  Anticoagulant therapy

6.  Closure of atrial septal defect

7.  Catheter ablation

8.  Referral to arrhythmia specialist

**Note**: Interventions for the treatment of postural orthostatic
tachycardia syndrome (POTS) are considered in the original full text
guideline but are not specifically recommended since POTS is not a
disorder of the sinus node.

#### MAJOR OUTCOMES CONSIDERED

-   Cardioversion to sinus rhythm

-   Maintenance of sinus rhythm

-   Recurrence of atrial fibrillation

-   Heart rate control

-   Death/mortality rate

-   Adverse effects of treatment (e.g., hemorrhagic complications)

-   Quality of life

-   Cost effectiveness

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The American College of Cardiology/American Heart Association/European
Society of Cardiology (ACC/AHA/ESC) Writing Committee to Develop
Guidelines for the Management of Patients With Supraventricular
Tachycardias conducted a comprehensive review of the relevant
literature. Literature searches were conducted in the following
databases: PubMed/Medline, EMBASE, the Cochrane Library (including the
Cochrane Database of Systematic Reviews and the Cochrane Controlled
Trials Registry), and Best Evidence. Searches were limited to English
language sources and to human subjects. The references selected for this
document are exclusively peer-reviewed papers that are representative
but not all-inclusive.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

A.  (Highest) Derived from multiple randomized clinical trials

B.  (Intermediate) Data are based on a limited number of randomized
    trials, nonrandomized studies, or observational registries.

C.  (Lowest) Primary basis for the recommendation was expert consensus.

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The writing committee was composed of six members representing the
American College of Cardiology Foundation (ACCF) and the American Heart
Association (AHA), four members representing the European Society of
Cardiology (ESC), and one member representing the North American Society
for Pacing and Electrophysiology -- Heart Rhythm Society (NASPE). The
writing committee was chosen on the basis of willingness and
availability to participate actively in meetings and the production of
the final manuscript. Writing groups are specifically charged to perform
a formal literature review, weigh the strength of evidence for or
against a particular treatment or procedure, and estimate expected
health outcomes where data exist. Patient-specific modifiers,
comorbidities, and issues of patient preference that might influence the
choice of particular tests or therapies are considered, as are frequency
of follow-up and cost effectiveness. In controversial areas, or with
regard to issues without evidence other than usual clinical practice, a
consensus was achieved by agreement of the expert panel after thorough
deliberations.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Class I**: Conditions for which there is evidence and/or general
agreement that a given procedure or treatment is useful and effective.

**Class II**: Conditions for which there is conflicting evidence and/or
a divergence of opinion about the usefulness/efficacy of a procedure or
treatment.

**Class IIa**: Weight of evidence/opinion is in favor of
usefulness/efficacy

**Class IIb**: Usefulness/efficacy is less well established by evidence
or opinion

**Class III**: Conditions for which there is evidence and/or general
agreement that the procedure or treatment is not useful/effective and in
some cases may be harmful.

#### COST ANALYSIS

A study compared the effect on quality of life between catheter ablation
and pharmacologic therapy as an initial strategy for patients with
supraventricular tachycardias (SVTs). Both treatments improved quality
of life and decreased frequency of disease-specific symptoms, but
ablation improved quality of life in more general health categories and
resulted in complete amelioration of symptoms in more patients (74 vs.
33%) than did medication. Potential long-term costs were similar for
medication and ablation. Among patients who had monthly episodes of
supraventricular tachycardias, radiofrequency (RF) ablation was,
however, the more effective and less expensive therapy compared with
long-term drug therapy.

Another prospective study compared the long-term effects on health
outcome of catheter ablation and medical therapy as an initial treatment
for patients with newly documented paroxysmal supraventricular
tachycardia (PSVT), excluding those with drug-refractory symptoms
referred specifically for ablation. At 5-year follow-up, patients who
received ablation had improved quality-of-life scores and a reduction in
disease-specific symptoms when compared with patients who continued to
take medical therapy. More patients reported complete elimination of
symptoms with ablation therapy (70%) than did those taking medical
therapy (43%). Over 5 years, the average cumulative cost for patients in
the medical therapy group was statistically significantly lower than in
patients initially treated with ablation therapy: \$6249 plus or minus
\$1421 per patient versus \$7507 plus or minus \$1098 per patient. It
was concluded that patient preference remains the critical determinant
in choosing a particular treatment in cases of mildly to moderately
symptomatic paroxysmal supraventricular tachycardia.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

This document was peer reviewed by two official external reviewers
representing the American College of Cardiology Foundation (ACCF), two
official external reviewers representing the American Heart Association
(AHA), and two official external reviewers representing the European
Society of Cardiology (ESC). The North American Society for Pacing and
Electrophysiology-Heart Rhythm Society assigned one organizational
reviewer to the guideline. In addition, 37 external content reviewers
participated in the review representing the ACC/AHA Task Force on
Practice Guidelines, the ESC Committee for Practice Guidelines, the
American College of Cardiology Foundation Electrophysiology Committee,
the AHA Electrocardiogram (ECG)/Arrhythmias Committee, the ESC Working
Group on Arrhythmias, and the ESC Task Force on Grown-Up Congenital
Heart Disease.

This document was approved by the ACCF Board of Trustees in August 2003,
by the AHA Science Advisory and Coordinating Committee in July 2003, and
by the ESC Committee for Practice Guidelines in July 2003.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Definitions for the weight of the evidence (A-C) and classes of
recommendations (I-III) can be found at the end of the \"Major
Recommendations\" field.

**Note**: The order in which treatment recommendations appear in the
following tables within each class of recommendation does not
necessarily reflect a preferred sequence of administration. Please refer
to the original guideline document for details. For pertinent drug
dosing information, please refer to the National Guideline Clearinghouse
summary [ACC/AHA/ESC Guidelines on the Management of Patients With
Atrial
Fibrillation](http://www.guideline.gov/summary/summary.aspx?doc_id=9661&nbr=005176).

**Recommendations for Acute Management of Hemodynamically Stable and
Regular Tachycardia**

+-------------------+----------------+------------+--------+----------+
| **ECG**           | **Recom        | **Classi   | *      | **Refe   |
|                   | mendation^1^** | fication** | *Level | rences** |
|                   |                |            | of     |          |
|                   |                |            | Evid   |          |
|                   |                |            | ence** |          |
+===================+================+============+========+==========+
| **Narrow          |                |            |        |          |
| QRS-complex       |                |            |        |          |
| tachycardia       |                |            |        |          |
| (SVT)**           |                |            |        |          |
+-------------------+----------------+------------+--------+----------+
|                   | Vagal          | I          | B      |          |
|                   | maneuvers      |            |        |          |
+-------------------+----------------+------------+--------+----------+
|                   | Adenosine      | I          | A      | Glatter  |
|                   |                |            |        | et al.,  |
|                   |                |            |        | 1999;    |
|                   |                |            |        | Cairns & |
|                   |                |            |        | Niemann, |
|                   |                |            |        | 1991;    |
|                   |                |            |        | Rankin   |
|                   |                |            |        | et al.,  |
|                   |                |            |        | 1992     |
+-------------------+----------------+------------+--------+----------+
|                   | Verapamil,     | I          | A      | Waxman   |
|                   | diltiazem      |            |        | et al.,  |
|                   |                |            |        | 1981     |
+-------------------+----------------+------------+--------+----------+
|                   | Beta blockers  | IIb        | C      | Am       |
|                   |                |            |        | sterdam, |
|                   |                |            |        | Kulcyski |
|                   |                |            |        | &        |
|                   |                |            |        | R        |
|                   |                |            |        | idgeway, |
|                   |                |            |        | 1991;    |
|                   |                |            |        | Das et   |
|                   |                |            |        | al.,     |
|                   |                |            |        | 1988     |
+-------------------+----------------+------------+--------+----------+
|                   | Amiodarone     | IIb        | C      | Holt et  |
|                   |                |            |        | al.,     |
|                   |                |            |        | 1985     |
+-------------------+----------------+------------+--------+----------+
|                   | Digoxin        | IIb        | C      |          |
+-------------------+----------------+------------+--------+----------+
| **Wide            |                |            |        |          |
| QRS-complex       |                |            |        |          |
| tachycardia**     |                |            |        |          |
+-------------------+----------------+------------+--------+----------+
| -   SVT + BBB     | See above      |            |        |          |
+-------------------+----------------+------------+--------+----------+
| -   Pre-excited   | Flecainide^3^  | I          | B      | H        |
|     SVT/AF^2^     |                |            |        | ohnloser |
|                   |                |            |        | & Zabel, |
|                   |                |            |        | 1992     |
+-------------------+----------------+------------+--------+----------+
|                   | Ibutilide^3^   | I          | B      | Glatter, |
|                   |                |            |        | D        |
|                   |                |            |        | orostkar |
|                   |                |            |        | & Yang,  |
|                   |                |            |        | 2001     |
+-------------------+----------------+------------+--------+----------+
|                   | P              | I          | B      |          |
|                   | rocainamide^3^ |            |        |          |
+-------------------+----------------+------------+--------+----------+
|                   | DC             | I          | C      |          |
|                   | cardioversion  |            |        |          |
+-------------------+----------------+------------+--------+----------+
| -   Wide          | P              | I          | B      | Gorgels  |
|     QRS-complex   | rocainamide^3^ |            |        | et al.,  |
|     tachycardia   |                |            |        | 1996;    |
|     of unknown    |                |            |        | Manz et  |
|     origin        |                |            |        | al.,     |
|                   |                |            |        | 1992     |
+-------------------+----------------+------------+--------+----------+
|                   | Sotalol^3^     | I          | B      | Ho et    |
|                   |                |            |        | al.,     |
|                   |                |            |        | 1994     |
+-------------------+----------------+------------+--------+----------+
|                   | Amiodarone     | I          | B      | Boineau  |
|                   |                |            |        | et al.,  |
|                   |                |            |        | 1980;    |
|                   |                |            |        | S        |
|                   |                |            |        | cheinman |
|                   |                |            |        | et al.,  |
|                   |                |            |        | 1995     |
+-------------------+----------------+------------+--------+----------+
|                   | DC             | I          | B      | Part 1:  |
|                   | cardioversion  |            |        | Intr     |
|                   |                |            |        | oduction |
|                   |                |            |        | to the   |
|                   |                |            |        | Inter    |
|                   |                |            |        | national |
|                   |                |            |        | Gu       |
|                   |                |            |        | idelines |
|                   |                |            |        | 2000 for |
|                   |                |            |        | CPR and  |
|                   |                |            |        | ECC,     |
|                   |                |            |        | 2000     |
+-------------------+----------------+------------+--------+----------+
|                   | Lidocaine      | IIb        | B      | Manz et  |
|                   |                |            |        | al.,     |
|                   |                |            |        | 1992; Ho |
|                   |                |            |        | et al.,  |
|                   |                |            |        | 1994     |
+-------------------+----------------+------------+--------+----------+
|                   | Adenosine^4^   | IIb        | C      | Sharma,  |
|                   |                |            |        | Klein &  |
|                   |                |            |        | Yee,     |
|                   |                |            |        | 1990     |
+-------------------+----------------+------------+--------+----------+
|                   | Beta           | III        | C      | Part 1:  |
|                   | blockers^5^    |            |        | Intr     |
|                   |                |            |        | oduction |
|                   |                |            |        | to the   |
|                   |                |            |        | Inter    |
|                   |                |            |        | national |
|                   |                |            |        | Gu       |
|                   |                |            |        | idelines |
|                   |                |            |        | 2000 for |
|                   |                |            |        | CPR and  |
|                   |                |            |        | ECC,     |
|                   |                |            |        | 2000     |
+-------------------+----------------+------------+--------+----------+
|                   | Verapamil^6^   | III        | B      | Buxton   |
|                   |                |            |        | et al.,  |
|                   |                |            |        | 1987     |
+-------------------+----------------+------------+--------+----------+
| **Wide            | Amiodarone     | I          | B      | Boineau  |
| QRS-complex       |                |            |        | et al.,  |
| tachycardia of    |                |            |        | 1980;    |
| unknown origin in |                |            |        | S        |
| patients with     |                |            |        | cheinman |
| poor LV           |                |            |        | et al.,  |
| function**        |                |            |        | 1995     |
+-------------------+----------------+------------+--------+----------+
|                   | DC             | I          | B      | Part 1:  |
|                   | cardioversion, |            |        | Intr     |
|                   | lidocaine      |            |        | oduction |
|                   |                |            |        | to the   |
|                   |                |            |        | Inter    |
|                   |                |            |        | national |
|                   |                |            |        | Gu       |
|                   |                |            |        | idelines |
|                   |                |            |        | 2000 for |
|                   |                |            |        | CPR and  |
|                   |                |            |        | ECC,     |
|                   |                |            |        | 2000     |
+-------------------+----------------+------------+--------+----------+

^1^All listed drugs are administered intravenously.

^2^See Section V-D.

^3^Should not be taken by patients with reduced LV function.

^4^Adenosine should be used with caution in patients with severe
coronary artery disease because vasodilation of normal coronary vessels
may produce ischemia in vulnerable territory. It should be used only
with full resuscitative equipment available.

^5^Beta blockers may be used as first-line therapy for those with
catecholamine-sensitive tachycardias, such as right ventricular outflow
tachycardia.

^6^Verapamil may be used as first-line therapy for those with LV
fascicular VT.

Abbreviations: AF, atrial fibrillation; BBB, bundle-branch block; DC,
direct current; ECG, electrocardiogram; LV, left ventricular; QRS,
ventricular activation on ECG; SVT, supraventricular tachycardia; VT,
ventricular tachycardia

**Recommendations for Treatment of Inappropriate Sinus Tachycardia**

  ----------------------------------------------------------------------------------------------------
  **Treatment**        **Recommendation**           **Classification**   **Level of   **References**
                                                                         Evidence**   
  -------------------- ---------------------------- -------------------- ------------ ----------------
  **Medical**          Beta blockers                I                    C             

                       Verapamil, diltiazem         IIa                  C             

  **Interventional**   Catheter ablation---sinus    IIb                  C            Sato et al.,
                       node                                                           2000; Mischke,
                       modification/elimination\*                                     Stellbrink &
                                                                                      Hanrath, 2001;
                                                                                      Man et al.,
                                                                                      2000; Lee et
                                                                                      al., 1995; Yee
                                                                                      et al., 1984;
                                                                                      Esmailzadeh et
                                                                                      al., 1997; de
                                                                                      Paola et al.,
                                                                                      1992;
                                                                                      Jayaprakash,
                                                                                      Sparks & Vohra,
                                                                                      1997
  ----------------------------------------------------------------------------------------------------

\*Used as a last resort.

**Recommendations for Long-Term Treatment of Patients With Recurrent
AVNRT**

  --------------------------------------------------------------------------------------------------
  **Clinical             **Recommendation**   **Classification**   **Level of   **References**
  Presentation**                                                   Evidence**   
  ---------------------- -------------------- -------------------- ------------ --------------------
  **Poorly tolerated     Catheter ablation    I                    B            Akhtar et al., 1993
  AVNRT with hemodynamic                                                        
  intolerance**                                                                 

                         Verapamil,           IIa                  C            Akhtar et al., 1993
                         diltiazem, beta                                        
                         blockers, sotalol,                                     
                         amiodarone                                             

                         Flecainide,^1^       IIa                  C             
                         propafenone^1^                                         

  **Recurrent            Catheter ablation    I                    B            Akhtar et al., 1993
  symptomatic AVNRT**                                                           

                         Verapamil            I                    B            Mauritson et al.,
                                                                                1982

                         Diltiazem, beta      I                    C            Winniford, Fulton &
                         blockers                                               Hillis, 1984

                         Digoxin^2^           IIb                  C             

  **Recurrent AVNRT      Flecainide^1^        IIa                  B            Tendera et al.,
  unresponsive to beta   propafenone,^1^                                        2001; Anderson et
  blockade or            sotalol                                                al., 1994;
  calcium-channel                                                               Pritchett, McCarthy
  blocker and patient                                                           & Wilkinson, 1991;
  not desiring RF                                                               Wanless et al.,
  ablation**                                                                    1997; Henthorn et
                                                                                al., 1991; \"A
                                                                                randomized,
                                                                                placebo-controlled
                                                                                trial,\" 1995

                         Amiodarone           IIb                  C            Gambhir et al., 1996

  **AVNRT with           Catheter ablation    I                    B             
  infrequent or single                                                          
  episode in patients                                                           
  who desire complete                                                           
  control of                                                                    
  arrhythmia**                                                                  

  **Documented PSVT with Verapamil,           I                    C             
  only dual AV-nodal     diltiazem, beta                                        
  pathways or single     blockers,                                              
  echo beats             flecainide^1^,                                         
  demonstrated during    propafenone^1^                                         
  electrophysiological                                                          
  study and no other                                                            
  identified cause of                                                           
  arrhythmia**                                                                  

                         Catheter ablation^3^ I                    B             

  **Infrequent,          No therapy           I                    C            Akhtar et al., 1993
  well-tolerated AVNRT**                                                        

                         Vagal maneuvers      I                    B             

                         Pill-in-the-pocket   I                    B             

                         Verapamil,           I                    B             
                         diltiazem, beta                                        
                         blockers                                               

                         Catheter ablation    I                    B            Bogun et al., 1996
  --------------------------------------------------------------------------------------------------

^1^Relatively contraindicated for patients with coronary artery disease,
LV dysfunction, or other significant heart disease.

^2^Digoxin is often ineffective because pharmacological effects can be
overridden by enhanced sympathetic tone.

^3^Decision depends on symptoms.

Abbreviations: AV, atrioventricular; AVNRT, atrioventricular nodal
reciprocating tachycardia; LV, left ventricular; PSVT, paroxysmal
supraventricular tachycardia; RF, radiofrequency

**Recommendations for Treatment of Focal and Nonparoxysmal Junctional
Tachycardia Syndromes**

  --------------------------------------------------------------------------------------------
  **Tachycardia**      **Recommendation**   **Classification**   **Level of   **References**
                                                                 Evidence**   
  -------------------- -------------------- -------------------- ------------ ----------------
  **Focal junctional   Beta blockers        IIa                  C             
  tachycardia**                                                               

                       Flecainide           IIa                  C            Kuck et al.,
                                                                              1988

                       Propafenone^1^       IIa                  C            Paul et al.,
                                                                              1992

                       Sotalol^1^           IIa                  C            Maragnes,
                                                                              Fournier &
                                                                              Davignon, 1992

                       Amiodarone^1^        IIa                  C            Fidell et al.,
                                                                              1973; Villain et
                                                                              al., 1990

                       Catheter ablation    IIa                  C            Hamdan,
                                                                              Dorostkar,
                                                                              Scheinmann,
                                                                              2000; Ehlert et
                                                                              al., 1993;
                                                                              Hamdan et al.,
                                                                              1996; Scheinman
                                                                              et al., 1994

  **Nonparoxysmal      Reverse digitalis    I                    C            Castellanos,
  junctional           toxicity                                               Sung & Myerburg,
  tachycardia**                                                               1979; Storstein
                                                                              et al., 1977

                       Correct hypokalemia  I                    C             

                       Treat myocardial     I                    C            Fisch, 1970
                       ischemia                                               

                       Beta blockers,       IIa                  C            Lee et al.,
                       calcium-channel                                        1999; Breslow,
                       blockers                                               Evers &
                                                                              Lebowitz, 1985
  --------------------------------------------------------------------------------------------

^1^Data available for pediatric patients only.

**Recommendations for Long-Term Therapy of Accessory Pathway-Mediated
Arrhythmias**

  ---------------------------------------------------------------------------------------------------------
  **Arrhythmia**       **Recommendation**                **Classification**   **Level of   **References**
                                                                              Evidence**   
  -------------------- --------------------------------- -------------------- ------------ ----------------
  **WPW syndrome       Catheter ablation                 I                    B            Scheinmann &
  (pre-excitation and                                                                      Huang, 2000;
  symptomatic                                                                              Jackman et al.,
  arrhythmias), well                                                                       1991; Manolis,
  tolerated**                                                                              Katsaros &
                                                                                           Cokkinos, 1992;
                                                                                           Zipes et al.,
                                                                                           1995

                       Flecainide, propafenone           IIa                  C            Henthorn et al.,
                                                                                           1991; Manolis,
                                                                                           Katsaros &
                                                                                           Cokkinos, 1992;
                                                                                           Janousek et al.,
                                                                                           1993; Musto et
                                                                                           al., 1988;
                                                                                           Vignati, Mauri &
                                                                                           Figini, 1993;
                                                                                           Vassiliadis et
                                                                                           al., 1990; Helmy
                                                                                           et al., 1990;
                                                                                           Kim, Lal &
                                                                                           Ruffy, 1986;
                                                                                           Cockrell et al.,
                                                                                           1991; Hoff et
                                                                                           al., 1988;
                                                                                           Wiseman et al.,
                                                                                           1990; Benditt et
                                                                                           al., 1991;
                                                                                           Pritchett et
                                                                                           al., 1991;
                                                                                           Manolis & Estes,
                                                                                           1989

                       Sotalol, amiodarone, beta         IIa                  C            Kunze, Schluter
                       blockers                                                            & Kuck, 1987;
                                                                                           Mason, 1987;
                                                                                           Rosenbaum et
                                                                                           al., 1974;
                                                                                           Wellens et al.,
                                                                                           1976;
                                                                                           Kappenberger et
                                                                                           al., 1984

                       Verapamil, diltiazem, digoxin     III                  C            Lai et al., 1993

  **WPW syndrome (with Catheter ablation                 I                    B            Scheinman &
  AF and                                                                                   Huang, 2000;
  rapid-conduction or                                                                      Calkins et al.,
  poorly tolerated                                                                         1999; Jackman et
  AVRT)**                                                                                  al., 1991;
                                                                                           Calkins et al.,
                                                                                           1991; Kuck et
                                                                                           al., 1991;
                                                                                           Calkins et al.,
                                                                                           1992; Lesh et
                                                                                           al., 1993;
                                                                                           Scheinmann,
                                                                                           1995; Hindricks,
                                                                                           1993

  **AVRT, poorly       Catheter ablation                 I                    B            Scheinman &
  tolerated (no                                                                            Huang, 2000;
  pre-excitation)**                                                                        Calkins et al.,
                                                                                           1999; Jackman et
                                                                                           al., 1991;
                                                                                           Calkins et al.,
                                                                                           1991; Kuck et
                                                                                           al., 1991;
                                                                                           Calkins et al.,
                                                                                           1992; Lesh et
                                                                                           al., 1993;
                                                                                           Scheinmann,
                                                                                           1995; Hindricks,
                                                                                           1993

                       Flecainide, propafenone           IIa                  C            Henthorn et al.,
                                                                                           1991; Manolis,
                                                                                           Katsaros &
                                                                                           Cokkinos, 1992;
                                                                                           Janousek et al.,
                                                                                           1993; Musto et
                                                                                           al., 1988;
                                                                                           Vignati, Mauri &
                                                                                           Figini, 1993;
                                                                                           Vassiliadis et
                                                                                           al., 1990; Helmy
                                                                                           et al., 1990;
                                                                                           Kim, Lal &
                                                                                           Ruffy, 1986;
                                                                                           Cockrell et al.,
                                                                                           1991; Hoff et
                                                                                           al., 1988;
                                                                                           Wiseman et al.,
                                                                                           1990; Benditt et
                                                                                           al., 1991;
                                                                                           Pritchett et
                                                                                           al., 1991;
                                                                                           Manolis & Estes,
                                                                                           1989

                       Sotalol, amiodarone               IIa                  C            Kunze, Schluter
                                                                                           & Kuck, 1987;
                                                                                           Mason, 1987;
                                                                                           Rosenbaum et
                                                                                           al., 1974;
                                                                                           Wellens et al.,
                                                                                           1976;
                                                                                           Kappenberger et
                                                                                           al., 1984

                       Beta blockers                     IIb                  C            Lai et al., 1993

                       Verapamil, diltiazem, digoxin     III                  C            Lai et al., 1993

  **Single or          None                              I                    C             
  infrequent AVRT                                                                          
  episode(s) (no                                                                           
  pre-excitation)**                                                                        

                       Vagal maneuvers                   I                    B             

                       Pill-in-the-pocket---verapamil,   I                    B            Alboni et al.,
                       diltiazem, beta blockers                                            2001; Yeh et
                                                                                           al., 1985

                       Catheter ablation                 IIa                  B            Scheinman &
                                                                                           Huang, 2000;
                                                                                           Calkins et al.,
                                                                                           1999; Jackman et
                                                                                           al., 1991;
                                                                                           Calkins et al.,
                                                                                           1991; Kuck et
                                                                                           al., 1991;
                                                                                           Calkins et al.,
                                                                                           1992; Lesh et
                                                                                           al., 1993;
                                                                                           Scheinman, 1995;
                                                                                           Hindricks, 1993

                       Sotalol, amiodarone               IIb                  B            Kunze, Schluter
                                                                                           & Kuck, 1987;
                                                                                           Mason, 1987;
                                                                                           Rosenbaum et
                                                                                           al., 1974;
                                                                                           Wellens et al.,
                                                                                           1976;
                                                                                           Kappenberger et
                                                                                           al., 1984

                       Flecainide, propafenone           IIb                  C            Henthorn et al.,
                                                                                           1991; Manolis,
                                                                                           Katsaros &
                                                                                           Cokkinos, 1992;
                                                                                           Janousek et al.,
                                                                                           1993; Musto et
                                                                                           al., 1988;
                                                                                           Vignati, Mauri &
                                                                                           Figini, 1993;
                                                                                           Vassiliadis et
                                                                                           al., 1990; Helmy
                                                                                           et al., 1990;
                                                                                           Kim, Lal &
                                                                                           Ruffy, 1986;
                                                                                           Cockrell et al.,
                                                                                           1991; Hoff et
                                                                                           al., 1988;
                                                                                           Wiseman et al.,
                                                                                           1990; Benditt et
                                                                                           al., 1991;
                                                                                           Pritchett et
                                                                                           al., 1991;
                                                                                           Manolis & Estes,
                                                                                           1989; Lai et
                                                                                           al., 1993

                       Digoxin                           III                  C             

  **Pre-excitation,    None                              I                    C             
  asymptomatic**                                                                           

                       Catheter ablation                 IIa                  B            Scheinman &
                                                                                           Huang, 2000;
                                                                                           Calkins et al.,
                                                                                           1999; Jackman et
                                                                                           al., 1991;
                                                                                           Calkins et al.,
                                                                                           1991; Kuck et
                                                                                           al., 1991;
                                                                                           Calkins et al.,
                                                                                           1992; Lesh et
                                                                                           al., 1993;
                                                                                           Scheinman, 1995;
                                                                                           Hindricks, 1993
  ---------------------------------------------------------------------------------------------------------

Abbreviations: AF, atrial fibrillation; AVRT, atrioventricular
reciprocating tachycardia; WPW, Wolff-Parkinson-White

**Recommendations for Treatment of Focal Atrial Tachycardias^1^**

  ------------------------------------------------------------------------------------------------
  **Clinical        **Recommendation**          **Classification**   **Level of   **References**
  Situation**                                                        Evidence**   
  ----------------- --------------------------- -------------------- ------------ ----------------
  **Acute                                                                         
  treatment^2^**                                                                  

  A. Conversion                                                                   

  Hemodynamically   DC cardioversion            I                    B             
  unstable patient                                                                

  Hemodynamically   Adenosine                   IIa                  C            Markowitz et
  stable patient                                                                  al., 1999;
                                                                                  Engelstein et
                                                                                  al., 1994

                    Beta blockers               IIa                  C            Harrison et al.,
                                                                                  2001; Stock,
                                                                                  1966

                    Verapamil, diltiazem        IIa                  C            Steinbeck &
                                                                                  Hoffman, 1998;
                                                                                  Kunze et al.,
                                                                                  1986

                    Procainamide                IIa                  C             

                    Flecainide/propafenone      IIa                  C            Kunze et al.,
                                                                                  1986; Berns et
                                                                                  al., 1987;
                                                                                  Coumel, Leclercq
                                                                                  & Assayag, 1984;
                                                                                  Lesh, Kalman &
                                                                                  Olgin, 1996

                    Amiodarone, sotalol         IIa                  C            Wren, 1998;
                                                                                  Coumel, Leclercq
                                                                                  & Assayag, 1984;
                                                                                  Beaufort-Krol &
                                                                                  Bink-Boelkens,
                                                                                  1997; Carrasco
                                                                                  et al., 1985;
                                                                                  Kopelman &
                                                                                  Horowitz, 1989;
                                                                                  Prager et al.,
                                                                                  1993

  B. Rate           Beta blockers               I                    C            Harrison et al.,
  regulation (in                                                                  2001; Stock,
  absence of                                                                      1966
  digitalis                                                                       
  therapy)                                                                        

                    Verapamil, diltiazem        I                    C            Chen et al.,
                                                                                  1994

                    Digoxin                     IIb                  C             

  **Prophylactic                                                                  
  therapy**                                                                       

  Recurrent         Catheter ablation           I                    B            Hsieh & Chen,
  symptomatic AT                                                                  2002

                    Beta blockers,              I                    C             
                    calcium-channel blockers                                      

                    Disopyramide^3^             IIa                  C            Carrasco et al.,
                                                                                  1985

                    Flecainide/propafenone^3^   IIa                  C            Kunze et al.,
                                                                                  1986; Coumel,
                                                                                  Leclercq &
                                                                                  Assayag, 1984;
                                                                                  Lesh, Kalman &
                                                                                  Olgin, 1996;
                                                                                  Creamer, Nathan
                                                                                  & Camm, 1985;
                                                                                  Pool & Quart,
                                                                                  1988

                    Sotalol, amiodarone         IIa                  C            Wren, 1998;
                                                                                  Beaufort-Krol &
                                                                                  Bink-Boelkens,
                                                                                  1997; Carrasco
                                                                                  et al., 1985;
                                                                                  Kopelman &
                                                                                  Horowitz, 1989

  Asymptomatic or   Catheter ablation           I                    B             
  symptomatic                                                                     
  incessant ATs                                                                   

  Nonsustained and  No therapy                  I                    C             
  asymptomatic                                                                    

                    Catheter ablation           III                  C             
  ------------------------------------------------------------------------------------------------

^1^Excluded are patients with MAT in whom beta blockers and sotalol are
often contraindicated due to pulmonary disease.

^2^All listed drugs for acute treatment are taken intravenously.

^3^Flecainide, propafenone, and disopyramide should not be used unless
they are combined with an AV-nodal---blocking agent.

Abbreviations: AT, atrial tachycardia; DC, direct current; MAT,
multifocal atrial tachycardia

**Recommendations for Acute Management of Atrial Flutter**

+-------------------+----------------+------------+--------+----------+
| **Clinical        | **Recom        | **Classi   | *      | **Refe   |
| Status/Proposed   | mendation^1^** | fication** | *Level | rences** |
| Therapy**         |                |            | of     |          |
|                   |                |            | Evid   |          |
|                   |                |            | ence** |          |
+===================+================+============+========+==========+
| **Poorly          |                |            |        |          |
| tolerated**       |                |            |        |          |
+-------------------+----------------+------------+--------+----------+
| -   Conversion    | DC             | I          | C      |          |
|                   | cardioversion  |            |        |          |
+-------------------+----------------+------------+--------+----------+
| -   Rate control  | Beta blockers  | IIa        | C      |          |
+-------------------+----------------+------------+--------+----------+
|                   | Verapamil or   | IIa        | C      |          |
|                   | diltiazem      |            |        |          |
+-------------------+----------------+------------+--------+----------+
|                   | Digitalis^2^   | IIb        | C      |          |
+-------------------+----------------+------------+--------+----------+
|                   | Amiodarone     | IIb        | C      |          |
+-------------------+----------------+------------+--------+----------+
| **Stable          |                |            |        |          |
| flutter**         |                |            |        |          |
+-------------------+----------------+------------+--------+----------+
| -   Conversion    | Atrial or      | I          | A      | Doni et  |
|                   | t              |            |        | al.,     |
|                   | ransesophageal |            |        | 2000;    |
|                   | pacing         |            |        | Rostas,  |
|                   |                |            |        | Antal &  |
|                   |                |            |        | Putorek, |
|                   |                |            |        | 1999;    |
|                   |                |            |        | Tucker & |
|                   |                |            |        | Wilson,  |
|                   |                |            |        | 1993;    |
|                   |                |            |        | Doni et  |
|                   |                |            |        | al.,     |
|                   |                |            |        | 1995;    |
|                   |                |            |        | Doni et  |
|                   |                |            |        | al.,     |
|                   |                |            |        | 1996     |
+-------------------+----------------+------------+--------+----------+
|                   | DC             | I          | C      | Lown,    |
|                   | cardioversion  |            |        | 1967     |
+-------------------+----------------+------------+--------+----------+
|                   | Ibutilide^3^   | IIa        | A      | Stambler |
|                   |                |            |        | et al.,  |
|                   |                |            |        | 1996;    |
|                   |                |            |        | El       |
|                   |                |            |        | lenbogen |
|                   |                |            |        | et al.,  |
|                   |                |            |        | 1996     |
+-------------------+----------------+------------+--------+----------+
|                   | Flecainide^4^  | IIb        | A      | Suttorp  |
|                   |                |            |        | et al.,  |
|                   |                |            |        | 1990;    |
|                   |                |            |        | Kingma & |
|                   |                |            |        | Suttorp, |
|                   |                |            |        | 1992     |
+-------------------+----------------+------------+--------+----------+
|                   | Propafenone^4^ | IIb        | A      | Suttorp  |
|                   |                |            |        | et al.,  |
|                   |                |            |        | 1990;    |
|                   |                |            |        | Kingma & |
|                   |                |            |        | Suttorp, |
|                   |                |            |        | 1992     |
+-------------------+----------------+------------+--------+----------+
|                   | Sotalol        | IIb        | C      | Vos et   |
|                   |                |            |        | al.,     |
|                   |                |            |        | 1998;    |
|                   |                |            |        | Sung et  |
|                   |                |            |        | al.,     |
|                   |                |            |        | 1995     |
+-------------------+----------------+------------+--------+----------+
|                   | P              | IIb        | A      | Volgman  |
|                   | rocainamide^4^ |            |        | et al.,  |
|                   |                |            |        | 1998     |
+-------------------+----------------+------------+--------+----------+
|                   | Amiodarone     | IIb        | C      | H        |
|                   |                |            |        | ohnloser |
|                   |                |            |        | & Zabel, |
|                   |                |            |        | 1992;    |
|                   |                |            |        | Hou et   |
|                   |                |            |        | al.,     |
|                   |                |            |        | 1995     |
+-------------------+----------------+------------+--------+----------+
| -   Rate control  | Diltiazem or   | I          | A      | Waxman   |
|                   | verapamil      |            |        | et al.,  |
|                   |                |            |        | 1981;    |
|                   |                |            |        | Schreck, |
|                   |                |            |        | Rivera & |
|                   |                |            |        | Tr       |
|                   |                |            |        | icarico, |
|                   |                |            |        | 1997;    |
|                   |                |            |        | Platia   |
|                   |                |            |        | et al.,  |
|                   |                |            |        | 1989;    |
|                   |                |            |        | Go       |
|                   |                |            |        | ldenberg |
|                   |                |            |        | et al.,  |
|                   |                |            |        | 1994     |
+-------------------+----------------+------------+--------+----------+
|                   | Beta blockers  | I          | C      | Platia   |
|                   |                |            |        | et al.,  |
|                   |                |            |        | 1989     |
+-------------------+----------------+------------+--------+----------+
|                   | Digitalis^2^   | IIb        | C      | Schreck, |
|                   |                |            |        | Rivera & |
|                   |                |            |        | Tr       |
|                   |                |            |        | icarico, |
|                   |                |            |        | 1997     |
+-------------------+----------------+------------+--------+----------+
|                   | Amiodarone     | IIb        | C      | Hou et   |
|                   |                |            |        | al.,     |
|                   |                |            |        | 1995     |
+-------------------+----------------+------------+--------+----------+

Cardioversion should be considered only if the patient is anticoagulated
(INR equals 2 to 3), the arrhythmia is less than 48 hours in duration,
or the TEE shows no atrial clots.

^1^All drugs are administered intravenously.

^2^Digitalis may be especially useful for rate control in patients with
heart failure.

^\<3^Ibutilide should not be used in patients with reduced LV function.

^4^Flecainide, propafenone, and procainamide should not be used unless
they are combined with an AV-nodal-blocking agent.

Abbreviations: AV, atrioventricular; DC, direct current; INR,
international normalized ratio; LV, left ventricular; TEE,
transesophageal echocardiography

**Recommendations for Long-Term Management of Atrial Flutter**

  ---------------------------------------------------------------------------------------------
  **Clinical            **Recommendation**   **Classification**   **Level of   **References**
  Status/Proposed                                                 Evidence**   
  Therapy**                                                                    
  --------------------- -------------------- -------------------- ------------ ----------------
  **First episode and   Cardioversion alone  I                    B            Lown, 1967
  well-tolerated atrial                                                        
  flutter**                                                                    

                        Catheter ablation^1^ IIa                  B            Natale et al.,
                                                                               2000

  **Recurrent and       Catheter ablation^1^ I                    B            Willems et al.,
  well-tolerated atrial                                                        2000; Kottkamp
  flutter**                                                                    et al., 2000;
                                                                               Chen et al.,
                                                                               1996

                        Dofetilide           IIa                  C            Singh et al.,
                                                                               2000; Pedersen
                                                                               et al., 2001

                        Amiodarone, sotalol, IIb                  C            Hohnloser &
                        flecainide,^2^ ^3^                                     Zabel, 1992;
                        quinidine,^2^, ^3^                                     Benditt et al.,
                        propafenone,^2^, ^3^                                   1999; Naccarelli
                        procainamide,^2^ ^3^                                   et al., 1996
                        disopyramide^2^ ^3^                                    

  **Poorly tolerated    Catheter ablation^1^ I                    B            Willems et al.,
  atrial flutter**                                                             2000; Kottkamp
                                                                               et al., 2000;
                                                                               Chen et al.,
                                                                               1996

  **Atrial flutter      Catheter ablation^1^ I                    B            Reithmann et
  appearing after use                                                          al., 2000; Huang
  of class Ic agents or                                                        et al., 1998
  amiodarone for                                                               
  treatment of AF**                                                            

                        Stop current drug    IIa                  C             
                        and use another                                        

  **Symptomatic         Catheter ablation^1^ IIa                  B            Akar et al.,
  non---CTI-dependent                                                          2001; Chan et
  flutter after failed                                                         al., 2000;
  antiarrhythmic drug                                                          Delacretaz et
  therapy**                                                                    al., 2001
  ---------------------------------------------------------------------------------------------

^1^Catheter ablation of the AV junction and insertion of a pacemaker
should be considered if catheter ablative cure is not possible and the
patient fails drug therapy.

^2^These drugs should not be taken by patients with significant
structural cardiac disease. Use of anticoagulants is identical to that
described for patients with AF.

^3^Flecainide, propafenone, procainamide, quinidine, and disopyramide
should not be used unless they are combined with an AV-nodal-blocking
agent.

Abbreviations: AF, atrial fibrillation; AV, atrioventricular; CTI,
cavotricuspid isthmus

**Recommendations for Treatment Strategies for SVT During Pregnancy**

  -----------------------------------------------------------------------------------
  **Treatment Strategy**   **Recommendation**       **Classification**   **Level of
                                                                         Evidence**
  ------------------------ ------------------------ -------------------- ------------
  **Acute conversion of    Vagal maneuver           I                    C
  PSVT**                                                                 

                           Adenosine                I                    C

                           DC cardioversion         I                    C

                           Metoprolol, propranolol  IIa                  C

                           Verapamil                IIb                  C

  **Prophylactic therapy** Digoxin                  I                    C

                           Metoprolol^1^            I                    B

                           Propranolol^1^           IIa                  B

                           Sotalol,^1^              IIa                  C
                           flecainide^2^                                 

                           Quinidine,               IIb                  C
                           propafenone,^2^                               
                           verapamil                                     

                           Procainamide             IIb                  B

                           Catheter ablation        IIb                  C

                           Atenolol^3^              III                  B

                           Amiodarone               III                  C
  -----------------------------------------------------------------------------------

^1^Beta-blocking agents should not be taken in the first trimester, if
possible.

^2^Consider AV-nodal---blocking agents in conjunction with flecainide
and propafenone for certain tachycardias (see Section V).

^3^Atenolol is categorized in class C (drug classification for use
during pregnancy) by legal authorities in some European countries.

Abbreviations: AV, atrioventricular; DC, direct current; PSVT,
paroxysmal supraventricular tachycardia

**Recommendations for Treatment of SVTs in Adults With Congenital Heart
Disease**

+----------------+----------------+------------+---------+------------+
| **Condition**  | **Re           | **Classi   | **Level | **Re       |
|                | commendation** | fication** | of      | ferences** |
|                |                |            | Evi     |            |
|                |                |            | dence** |            |
+================+================+============+=========+============+
| **Failed       |                |            |         |            |
| antiarrhythmic |                |            |         |            |
| drugs and      |                |            |         |            |
| symptomatic:** |                |            |         |            |
+----------------+----------------+------------+---------+------------+
| -   Repaired   | Catheter       | I          | C       | Nakagawa   |
|     ASD        | ablation in an |            |         | et al.,    |
|                | experienced    |            |         | 2001;      |
|                | center         |            |         | Triedman   |
|                |                |            |         | et al.,    |
|                |                |            |         | 2001;      |
|                |                |            |         | Triedman   |
|                |                |            |         | et al.,    |
|                |                |            |         | 1995;      |
|                |                |            |         | Delacretaz |
|                |                |            |         | et al.,    |
|                |                |            |         | 2001; Hebe |
|                |                |            |         | et al.,    |
|                |                |            |         | 2000;      |
|                |                |            |         | Triedman   |
|                |                |            |         | et al.,    |
|                |                |            |         | 2002; Lesh |
|                |                |            |         | et al.,    |
|                |                |            |         | 1994;      |
|                |                |            |         | Triedman   |
|                |                |            |         | et al.,    |
|                |                |            |         | 1997       |
+----------------+----------------+------------+---------+------------+
| -   Mustard or | Catheter       | I          | C       | Triedman   |
|     Senning    | ablation in an |            |         | et al.,    |
|     repair of  | experienced    |            |         | 1995;      |
|                | center         |            |         | Delacretaz |
|  transposition |                |            |         | et al.,    |
|     of the     |                |            |         | 2001; Hebe |
|     great      |                |            |         | et al.,    |
|     vessels    |                |            |         | 2000;      |
|                |                |            |         | Triedman   |
|                |                |            |         | et al.,    |
|                |                |            |         | 2002       |
+----------------+----------------+------------+---------+------------+
| **Unrepaired   | Closure of the | III        | C       | Attie et   |
| asymptomatic   | ASD for        |            |         | al., 2001; |
| ASD not        | treatment of   |            |         | Donti et   |
| h              | the arrhythmia |            |         | al., 2001  |
| emodynamically |                |            |         |            |
| significant**  |                |            |         |            |
+----------------+----------------+------------+---------+------------+
| **Unrepaired   | Closure of the | I          | C       |            |
| h              | ASD combined   |            |         |            |
| emodynamically | with ablation  |            |         |            |
| significant    | of the flutter |            |         |            |
| ASD with       | isthmus        |            |         |            |
| atrial         |                |            |         |            |
| flutter\***    |                |            |         |            |
+----------------+----------------+------------+---------+------------+
| **PSVT and     | Surgical       | I          | C       | Huang et   |
| Ebstein\'s     | ablation of    |            |         | al., 2000; |
| anomaly with   | accessory      |            |         | Misaki et  |
| hemodynamic    | pathways at    |            |         | al., 1995  |
| indications    | the time of    |            |         |            |
| for surgical   | operative      |            |         |            |
| repair**       | repair of the  |            |         |            |
|                | malformation   |            |         |            |
|                | at an          |            |         |            |
|                | experienced    |            |         |            |
|                | center         |            |         |            |
+----------------+----------------+------------+---------+------------+

\*Conversion and antiarrhythmic drug therapy initial management as
described for atrial flutter (see Section V-F).

Abbreviations: ASD, atrial septal defect; PSVT, paroxysmal
supraventricular tachycardia

**Definitions**:

**Class I**: Conditions for which there is evidence and/or general
agreement that a given procedure or treatment is useful and effective.

**Class II**: Conditions for which there is conflicting evidence and/or
a divergence of opinion about the usefulness/efficacy of a procedure or
treatment.

**Class IIa**: Weight of evidence/opinion is in favor of
usefulness/efficacy

**Class IIb**: Usefulness/efficacy is less well established by evidence
or opinion

**Class III**: Conditions for which there is evidence and/or general
agreement that the procedure/treatment is not useful or effective and in
some cases may be harmful.

**Weight of Evidence**

A.  (Highest) Derived from multiple randomized clinical trials

B.  Intermediate) Data are based on a limited number of randomized
    trials, nonrandomized studies, or observational registries.

C.  (Lowest) Primary basis for the recommendation was consensus.

#### CLINICAL ALGORITHM(S)

Algorithms are provided in the original guideline document for:

-   Initial evaluation of patients with suspected tachycardia

-   Differential diagnosis for narrow ventricular activation on
    electrocardiogram (QRS) tachycardia

-   Response of narrow complex tachycardias to adenosine

-   Differential diagnosis for wide QRS-complex tachycardia (greater
    than 120 ms)

-   Acute management of patients with hemodynamically stable and regular
    tachycardia

-   Management of atrial flutter depending on hemodynamic stability

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=4155)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

Recommendations are evidence-based and derived primarily from published
data. The weight of evidence is given for each recommendation (see the
\"Major Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Effective management of patients with supraventricular arrhythmias with
appropriate use of diagnostic procedures and treatment with
pharmacologic and nonpharmacologic antiarrhythmic approaches

#### POTENTIAL HARMS

**Antiarrhythmic Drug Therapy**

-   A major concern accompanying the use of antiarrhythmic drugs,
    particularly when treating an arrhythmia that is not life
    threatening, such as supraventricular tachycardia (SVT), is the
    occurrence of ventricular proarrhythmia (e.g., torsade de pointes).
    A number of clinical factors increase the risk of proarrhythmia,
    including age, gender, fluid and electrolyte abnormalities, the
    presence of underlying heart disease, abnormalities of drug
    clearance, polypharmacy, and drug-drug interactions. Drug-induced
    slowing of the rate of atrial flutter with the production of
    one-to-one conduction to the ventricle represents a potentially
    life-threatening form of proarrhythmia unique to the treatment of
    SVT.

-   The potential benefit of class Ic agents should be balanced with the
    potential risks of proarrhythmia and toxicity. Because atrial
    tachycardia (ATs) commonly occur in older patients and in the
    context of structural heart disease, class Ic agents should be used
    only after coronary artery disease is excluded.

-   Potential adverse effects of adenosine include initiation of atrial
    fibrillation (AF) (1 to 15%), which is usually transient, and may be
    particularly problematic for those with ventricular pre-excitation.
    Adenosine should be avoided in patients with severe bronchial
    asthma. It is important to use extreme care with concomitant use of
    intravenous (IV) calcium-channel blockers and beta blockers because
    of possible potentiation of hypotensive and/or bradycardic effects.
    Hypotension and sinus bradycardia are rare complications of
    diltiazem plus propranolol.

-   Amiodarone is associated with organ toxicity and a high rate of
    discontinuation.

**Intravenous (IV) Antiarrhythmia Drugs**

-   Intravenous verapamil or diltiazem may be deleterious because they
    may precipitate hemodynamic collapse for a patient with ventricular
    tachycardia (VT).

-   In a study comparing IV flecainide with propafenone adverse effects
    included ventricular activation on electrocardiogram (ECG) (QRS)
    widening, dizziness, and paresthesias.

-   In one study adverse effects of IV sotalol included hypotension and
    dyspnea.

-   A review of the existing literature for IV antiarrhythmic drugs
    taken by patients with atrial flutter suggests that dofetilide or
    ibutilide are more effective than sotalol or class I agents but are
    associated with a significant incidence of torsades de pointes (1.5
    to 3%).

**Antiarrhythmic Drugs During Pregnancy**

-   Propranolol and metoprolol are generally considered to be safe but
    are best avoided in the first trimester of pregnancy. Rare cases of
    adverse effects on the fetus, including bradycardia, hypoglycemia,
    premature labor, and metabolic abnormalities, have been reported but
    may be secondary to fetal distress in high-risk pregnancies. The
    potential for intrauterine growth retardation has been reported with
    propranolol and has raised concerns, especially when it is taken in
    the first trimester. Later studies reported growth retardation in
    babies receiving atenolol in the first trimester and a higher
    prevalence of preterm delivery.

-   The use of amiodarone, a category D agent, in pregnancy should be
    restricted to arrhythmias that are resistant to other drugs or are
    life threatening.

-   Quinidine is considered to be relatively well tolerated during
    pregnancy, although isolated cases of adverse effects, such as fetal
    thrombocytopenia and eighth-nerve toxicity, have been reported

**Catheter Ablation**

-   Potential adverse effects include pericarditis, phrenic nerve
    injury, superior vena cava (SVC) syndrome, or need for permanent
    pacing.

-   Complications associated with catheter ablation of accessory
    pathways result from radiation exposure, vascular access (e.g.,
    hematomas, deep venous thrombosis, arterial perforation,
    arteriovenous fistula, pneumothorax), catheter manipulation (e.g.,
    valvular damage, microemboli, perforation of the coronary sinus or
    myocardial wall, coronary artery dissection, thrombosis), or
    delivery of radiofrequency (RF) energy (e.g., AV block, myocardial
    perforation, coronary artery spasm or occlusion, transient ischemic
    attacks, cerebrovascular accidents). The procedure-related mortality
    reported for catheter ablation of accessory pathways ranges from 0
    to 0.2%. The voluntary Multicentre European Radiofrequency Survey
    (MERFS) reported data from 2222 patients who underwent catheter
    ablation of an accessory pathway. The overall complication rate was
    4.4%, including 3 deaths (0.13%). The 1995 NASPE survey of 5427
    patients who underwent catheter ablation of an accessory pathway
    reported a total of 99 (1.82%) significant complications, including
    4 procedure-related deaths (0.08%). Among the 500 patients who
    underwent catheter ablation of an accessory pathway as part of a
    prospective, multicenter clinical trial, there was 1 death (0.2%).
    This patient died of dissection of the left main coronary artery
    during an attempt at catheter ablation of a left free-wall accessory
    pathway. The most common major complications are complete AV block
    and cardiac tamponade. The incidence of inadvertent complete AV
    block ranges from 0.17 to 1.0%. Most occur in the setting of
    attempted ablation of septal accessory pathways located close to the
    AV junction. The frequency of cardiac tamponade varies between 0.13
    and 1.1%.

**Subgroups Most Likely to Experience Harms**

-   Patients with structural heart defects may not be candidates for
    catheter ablation.

-   Ibutilide should not be used in patients with an ejection fraction
    of less than 30% due to increased risk of polymorphic ventricular
    tachycardia (VT). Intravenous ibutilide should not be taken by
    patients with severe structural cardiac diseases or prolonged QT
    interval, or in those with underlying sinus node disease.

-   Patients with kidney or liver disease are at increased risk of drug
    toxicity, including proarrhythmia with antiarrhythmic drugs.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

-   Class Ic agents (i.e., flecainide and propafenone) are
    contraindicated for patients with structural heart disease.

-   Flecainide and propafenone are relatively contraindicated for
    patients with coronary artery disease, left ventricular dysfunction,
    or other significant heart disease.

-   Beta blockers and sotalol are often contraindicated in patients with
    multifocal atrial tachycardia (MAT) due to pulmonary disease.

-   Contraindications for dofetilide include a creatinine clearance less
    than 20, hypokalemia, hypomagnesemia, and prolonged QT at baseline.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   These guidelines attempt to define practices that meet the needs of
    most patients in most circumstances. The ultimate judgment regarding
    care of a particular patient must be made by the physician and the
    patient in light of all of the circumstances presented by that
    patient. There are circumstances in which deviations from these
    guidelines are appropriate.

-   The guideline is a consensus document that includes evidence and
    expert opinions from several countries. The pharmacologic and
    nonpharmacologic antiarrhythmic approaches discussed may, therefore,
    include some drugs and devices that do not have the approval of
    governmental regulatory agencies.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm\
Personal Digital Assistant (PDA) Downloads\
Pocket Guide/Reference Cards\
Slide Presentation

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H,
Camm AJ, Campbell WB, Haines DE, Kuck KH, Lerman BB, Miller DD, Shaeffer
CW, Stevenson WG, Tomaselli GF. ACC/AHA/ESC guidelines for the
management of patients with supraventricular arrhythmias. A report of
the American College of Cardiology/American Heart Association Task Force
and the European Society of Cardiology Committee for Practice
Guidelines. Bethesda (MD): American College of Cardiology Foundation;
2003. 62 p. \[537 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003

#### GUIDELINE DEVELOPER(S)

American College of Cardiology Foundation - Medical Specialty Society\
American Heart Association - Professional Association\
European Society of Cardiology - Medical Specialty Society

#### SOURCE(S) OF FUNDING

The American College of Cardiology and the American Heart Association.
No outside funding accepted.

#### GUIDELINE COMMITTEE

Writing Committee to Develop Guidelines for the Management of Patients
With Supraventricular Arrhythmias

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee Members*: Carina Blomstrom-Lundqvist, MD, PhD, FACC, FESC
(Co-Chair); Melvin M. Scheinman, MD, FACC, (Co-Chair) Etienne M. Aliot,
MD, FACC, FESC; Joseph S. Alpert, MD, FACC, FAHA, FESC; Hugh Calkins,
MD, FACC, FAHA; A. John Camm, MD, FACC, FAHA, FESC; W. Barton Campbell,
MD, FACC, FAHA; David E. Haines, MD, FACC; Karl H. Kuck, MD, FACC, FESC;
Bruce B. Lerman, MD, FACC; D. Douglas Miller, MD, CM, FACC; Charlie
Willard Shaeffer, Jr., MD, FACC; William G. Stevenson, MD, FACC; Gordon
F. Tomaselli, MD, FACC, FAHA

*Task Force Members*: Elliott M. Antman, MD, FACC, FAHA, (Chair); Sidney
C. Smith, Jr., MD, FACC, FAHA, FESC (Vice Chair); Joseph S. Alpert, MD,
FACC, FAHA, FESC; David P. Faxon, MD, FACC, FAHA; Valentin Fuster, MD,
PhD, FACC, FAHA, FESC; Raymond J. Gibbons, MD, FACC, FAHA\*#; Gabriel
Gregoratos, MD, FACC, FAHA; Loren F. Hiratzka, MD, FACC, FAHA; Sharon
Ann Hunt, MD, FACC, FAHA; Alice K. Jacobs, MD, FACC, FAHA; Richard O.
Russell, Jr., MD, FACC, FAHA\*

*ESC Committee for Practice Guidelines Members*: Silvia G. Priori, MD,
PhD, FESC (Chair); Jean-Jacques Blanc, MD, PhD, FESC; Andzrej Budaj, MD,
FESC; Enrique Fernandez Burgos, MD; Martin Cowie, MD, PhD, FESC; Jaap
Willem Deckers, MD, PhD, FESC; Maria Angeles Alonso Garcia, MD, FESC;
Werner W. Klein, MD, FACC, FESC#; John Lekakis, MD, FESC; Bertil
Lindahl, MD; Gianfranco Mazzotta, MD, FESC; Joao Carlos Araujo Morais,
MD, FESC; Ali Oto, MD, FACC, FESC; Otto Smiseth, MD, PhD, FESC;
Hans-Joachim Trappe, MD, PhD, FESC

\*Former Task Force Member\
#Immediate Past Chair

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

The American College of Cardiology/American Heart Association (ACC/AHA)
Task Force on Practice Guidelines and the European Society of Cardiology
(ESC) Committee on Practice Guidelines make every effort to avoid any
actual or potential conflict of interest that might arise as a result of
an industry relationship or from personal biases of the writing panel.
Specifically, all members of the writing panel were asked to provide
disclosure statements of all such relationships that might be perceived
as real or potential conflicts of interest. These statements are
reported orally to all members of the writing panel during the first
meeting and are updated as changes occur.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American College of Cardiology
(ACC) Web
site](http://www.acc.org/qualityandscience/clinical/guidelines/arrhythmias/update_index.htm).
Copies are also available from the [American Heart Association (AHA) Web
site](http://www.americanheart.org/presenter.jhtml?identifier=3014995)
and from the [European Society of Cardiology (ESC) Web
site](http://www.escardio.org/guidelines-surveys/esc-guidelines/Pages/supraventricular-arrhythmias.aspx).

Print copies: Available from ACC, Educational Services, 9111 Old
Georgetown Road, Bethesda, MD 20814-1699. Also available from AHA,
Public Information 7272 Greenville Avenue, Dallas, TX 75231-4596
(Reprint No. 71-0112).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   ACC/AHA/ESC Guidelines for the management of patients with
    supraventricular arrhythmias\*\--Executive summary. A Report of the
    American College of Cardiology/American Heart Association Task Force
    on Practice Guidelines and the European Society of Cardiology
    Committee for Practice Guidelines (Writing Committee to Develop
    Guidelines for the Management of Patients With Supraventricular
    Arrhythmias). Available from the [American College of Cardiology
    (ACC) Web
    site](http://www.acc.org/qualityandscience/clinical/guidelines/arrhythmias/exec_summ/update_index.htm)
    and the [European Society of Cardiology (ESC) Web
    site](http://www.escardio.org/admin/GuidelinesReferences/guidelines-SVA-ES.pdf).

Print copies: Available from ACC, Educational Services, 9111 Old
Georgetown Road, Bethesda, MD 20814-1699. Also available from AHA,
Public Information 7272 Greenville Avenue, Dallas, TX 75231-4596
(Reprint No. 71-0112). Also available from ESC: Oxford University Press
(OUP), Great Clarendon Street, Oxford OX2 6DP, England, Tel: + 44
(0)1865 353907, Fax: + 44 (0)1865 353485.

The following are also available:

-   Management of patients with supraventricular arrhythmias. Pocket
    guidelines. Available from the [ESC Web
    site](http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/SVA-pocket.aspx).
    Also available for PDA download from the [ESC Web
    site](http://pocketgram.net/escardio/).

-   Slide set for superventricular arrhythimias. Electronic copies:
    Available from the [ESC Web
    site](http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-SVA-slides.pdf).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on March 11, 2004. The information
was verified by the guideline developer on May 9, 2005.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions as follows:

Copyright to the original guideline is owned by the American College of
Cardiology Foundation (ACCF), the American Heart Association, Inc.
(AHA), and the European Society of Cardiology (ESC). NGC users are free
to download a single copy for personal use. Reproduction without
permission of the ACC/AHA guidelines is prohibited. Permissions requests
should be directed to Patty Jones, 9111 Old Georgetown Rd, Bethesda, MD
20814-1699; telephone, (301) 493-2368; fax, (301) 897-9745.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008