ACC/AHA/ESC Practice Guideline 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) Developed in Collaboration With NASPE-Heart Rhythm Society Committee Members Carina Blomström-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; João Carlos Araujo Morais, MD, FESC; Ali Oto, MD, FACC, FESC; Otto Smiseth, MD, PhD, FESC; Hans-Joachim Trappe, MD, PhD, FESC *This document does not cover atrial fibrillation; atrial fibrillation is covered in the ACC/AHA/ESC guidelines on the management of patients with atrial fibrillation found on the ACC, AHA, and ESC Web sites. †Former Task Force Member ‡Immediate Past Chair This document was approved by the American College of Cardiology Foundation Board of Trustees in August 2003, by the American Heart Association Science Advisory and Coordinating Committee in July 2003, and by the European Society of Cardiology Committee for Practice Guidelines in July 2003. When citing this document, the American College of Cardiology Foundation, the American Heart Association, and the European Society of Cardiology request that the following citation format be used: Blomström-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—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.). Circulation 2003;108:1871–1909. This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org), the American Heart Association (www.americanheart.org), and the European Society of Cardiology (www.escardio.org), as well as published in the October 15, 2003, issue of the Journal of the American College of Cardiology, the October 14, 2003, issue of Circulation, and the 24/20 October 15, 2003, issue of the European Heart Journal. Single and bulk reprints of both the full-text guidelines and the executive summary are available from Elsevier Publishers by calling ϩ44.207.424.4200 or ϩ44.207.424.4389, faxing ϩ44.207.424.4433, or writing to Elsevier Publishers Ltd, European Heart Journal, ESC Guidelines—Reprints, 32 Jamestown Road, London, NW1 7BY, UK; or E-mail [email protected]. Single copies of executive summary and the full-text guidelines are also available by calling 800-253-4636 or writing the American College of Cardiology Foundation, Resource Center, at 9111 Old Georgetown Road, Bethesda, MD 20814-1699. To purchase bulk reprints (specify version and reprint number—executive summary 71-0261 and full-text guideline 71-0262): up to 999 copies, call 800-611-6083 (U.S. only) or fax 413-665-2671; 1000 or more copies, call 214-706-1789, fax 214-691-6342; or E-mail [email protected]. (Circulation. 2003;108:1871-1909.) © 2003 by the American College of Cardiology Foundation, the American Heart Association, Inc., and the European Society of Cardiology Circulation is available at http://www.circulationaha.org DOI: 10.1161/01.CIR.0000091380.04100.84 1871 1872 Circulation October 14, 2003 Table of Contents 1. Acute Conversion of Atrioventricular Node– Preamble .....................................1872 Dependent Tachycardias ................1901 I. Introduction ...............................1872 2. Prophylactic Antiarrhythmic Drug Therapy .1901 A. Organization of Committee and Evidence B. Supraventricular Tachycardias in Adult Review ................................1872 Patients With Congenital Heart Disease ......1901 B. Contents of These Guidelines—Scope .......1873 1. Introduction ..........................1902 II. Public Health Considerations and Epidemiology .1873 2. Specific Disorders .....................1902 III. General Mechanisms of Supraventricular Arrhythmia . .1874 C. Quality-of-Life and Cost Considerations .....1903 A. Specialized Atrial Tissue ..................1874 References ....................................1904 B. General Mechanisms .....................1874 IV. Clinical Presentation, General Evaluation, and Preamble Management of Patients With Supraven- These practice guidelines are intended to assist physicians in tricular Arrhythmia ...........................1874 clinical decision making by describing a range of generally A. General Evaluation of Patients Without acceptable approaches for the diagnosis and management of Documented Arrhythmia ..................1874 supraventricular arrhythmias. These guidelines attempt to 1. Clinical History and Physical Examination .1874 define practices that meet the needs of most patients in most 2. Diagnostic Investigations ...............1875 circumstances. The ultimate judgment regarding care of a 3. Management .........................1876 particular patient must be made by the physician and the B. General Evaluation of Patients With patient in light of all of the circumstances presented by that Documented Arrhythmia ...................1876 patient. There are situations in which deviations from these 1. Diagnostic Evaluation ..................1876 guidelines are appropriate. 2. Management .........................1878 V. Specific Arrhythmias ........................1880 I. Introduction A. Sinus Tachyarrhythmias ..................1880 A. Organization of Committee and 1. Physiological Sinus Tachycardia .........1880 Evidence Review 2. Inappropriate Sinus Tachycardia .........1881 Supraventricular arrhythmias are a group of common rhythm 3. Postural Orthostatic Tachycardia Syndrome .1883 disturbances. The most common treatment strategies include 4. Sinus Node Re-entry Tachycardia ........1883 antiarrhythmic drug therapy and catheter ablation. Over the past B. Atrioventricular Nodal Reciprocating Tachycardia .1884 decade, the latter has been shown to be a highly successful and 1. Definitions and Clinical Features .........1884 often curative intervention. To facilitate and optimize the man- 2. Acute Treatment ......................1884 agement of patients with supraventricular arrhythmias, the 3. Long-Term Pharmacologic Therapy ......1884 American College of Cardiology Foundation (ACCF), the 4. Catheter Ablation .....................1885 American Heart Association (AHA), and the European Society C. Focal and Nonparoxysmal Junctional Tachycardia .1886 of Cardiology (ESC) created a committee to establish guidelines 1. Focal Junctional Tachycardia ............1886 for better management of these heterogeneous tachyarrhythmias. 2. Nonparoxysmal Junctional Tachycardia . .1887 This document summarizes the management of patients with D. Atrioventricular Reciprocating Tachycardia supraventricular arrhythmias with recommendations for diag- (Extra Nodal Accessory Pathways) ..........1888 nostic procedures as well as indications for antiarrhythmic drugs 1. Sudden Death in WPW Syndrome and and/or nonpharmacologic treatments. Risk Stratification .....................1888 Writing groups are specifically charged to perform a 2. Acute Treatment ......................1889 formal literature review, weigh the strength of evidence for or 3. Long-Term Pharmacologic Therapy ......1889 against a particular treatment or procedure, and include 4. Catheter Ablation .....................1890 estimates of expected health outcomes where data exist. 5. Management of Patients With Asymptomatic Patient-specific modifiers, comorbidities, and issues of pa- Accessory Pathways ...................1891 tient preference that might influence the choice of particular 6. Summary of Management ..............1891 tests or therapies are considered, as are frequency of E. Focal Atrial Tachycardias .................1891 follow-up and cost effectiveness. In controversial areas, or 1. Definition and Clinical Presentation ......1891 with regard to issues