Europace Advance Access published November 17, 2016 Europace EHRA POSITION PAPER doi:10.1093/europace/euw301 European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacio´nCardiacay Electrofisiologia (SOLAECE) Demosthenes G. Katritsis, (Chair)1, Giuseppe Boriani2,FranciscoG.Cosio3, Gerhard Hindricks4,PierreJaı¨s5,MarkE.Josephson6, Roberto Keegan7, Young-Hoon Kim8, Bradley P. Knight9,Karl-HeinzKuck10,DeirdreA.Lane10,11, Downloaded from GregoryY.H.Lip11, Helena Malmborg12, Hakan Oral13, Carlo Pappone14, 15 16 Sakis Themistoclakis ,KathrynA.Wood , and Carina Blomstro¨m-Lundqvist, by guest on November 20, 2016 (Co-Chair)12 REVIEWERS: Bulent Gorenek, (review coordinator)17, Nikolaos Dagres4, Gheorge-Andrei Dan18, Marc A Vos19, Gulmira Kudaiberdieva20, Harry Crijns21, Kurt Roberts-Thomson22, Yenn-Jiang Lin23, Diego Vanegas24, Walter Reyes Caorsi25, Edmond Cronin26, and Jack Rickard27 1Athens Euroclinic, Athens, Greece; and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; 2Cardiology Department, Modena University Hospital, University of Modena and Reggio Emilia, Modena, Italy; 3Hospital Universitario De Getafe, Madrid, Spain; 4University of Leipzig, Heartcenter, Leipzig, Germany; 5University of Bordeaux, CHU Bordeaux, LIRYC, France; 6Berth Israel Deaconess Medical Center, Boston, MA, USA; 7Hospital Privado del Sur y Hospital Espan˜ol, Bahia Blanca, Argentina; 8Korea University Medical Center, Seoul, Republic of Korea; 9Northwestern Memorial Hospital, Chicago, IL, USA; 10Asklepios Hospital St Georg, Hamburg, Germany; 11University of Birmingham Institute of Cardiovascular Science, City Hospital, Birmingham, UK; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; 12Department of Cardiology and Medical Science, Uppsala University, Uppsala, Sweden; 13University of Michigan, Ann Arbor, MI, USA; 14IRCCS Policlinico San Donato, San Donato Milanese, Italy; 15Dell’Angelo Hosiptal, Venice-Mestre, Italy; 16Emory University School of Nursing, Atlanta, USA; 17Cardiology Department, Eskisehir Osmangazi University, Eskisehir, Turkey; 18Colentina University Hospital, ‘Carol Davila’ University of Medicine, Bucharest, Romania; 19Department of Medical Physiology, Division Heart and Lungs, Umc Utrecht, The Netherlands; 20Adana, Turkey; 21 Mastricht University Medical Centre, Cardiology & CARIM, The Netherlands; 22Royal Adelaide Hospital, Adelaide, Australia; 23Taipei Veterans General Hospital, Taipei, Taiwan; 24Hospital Militar Central - Unidad de Electrofisiologı`a - FUNDARRITMIA, Bogota`, Colombia; 25 Centro Cardiovascular Casa de Galicia, Montevideo, Uruguay; 26Hartford Hospital, Hartford, USA; and 27Cleveland Clinic, Cleveland, Ohio, USA Table of contents Wide QRS (.120 ms) Tachycardias . ....................9 Acute management in the absence of an established diagnosis Abbreviations . .........................................2 Acute management of narrow QRS tachycardia........... 14 Preamble/Definitions Acute management of wide QRS tachycardia . ............ 15 Evidence review . .....................................2 Atrial tachycardias Relationships with industry and other conflicts. ............3 Sinus tachycardias ................................... 16 Definitions and classification.............................3 Focal atrial tachycardias. .............................. 17 Epidemiology . .........................................3 Macroreentrant atrial tachycardias ...................... 20 Clinical presentation . ...................................4 Atrioventricular junctional tachycardias Differential diagnosis of tachycardias Atrioventricular nodal reentrant tachycardia . ............ 25 Narrow QRS (≤120 ms) Tachycardias . ..................5 Non-paroxysmal junctional tachycardia.................. 28 Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2016. For permissions please email: [email protected]. Page 2 of 47 D.G. Katritsis et al. Focal junctional tachycardia . ........................ 28 RV: right ventricle Other non-reentrant variants . ........................ 28 s: seconds Atrioventricular reentrant tachycardias SR: sinus rhythm Wolff–Parkinson–White syndrome and atrioventricular re- SVC: superior vena cava entrant tachycardias . .............................. 28 SVT: supraventricular tachycardia Concealed and other accessory pathways................ 30 VA: ventricular arrhythmia The asymptomatic patient with ventricular pre-excitation. 31 WPW: Wolff–Parkinson–White Supraventricular tachycardia in adult congenital heart disease . 32 Supraventricular tachycardia in pregnancy. .................34 Health economics . ...................................36 Preamble/definitions Patient preferences . ...................................36 Areas for future research . .............................37 Supraventricular arrhythmias are common, and patients are often symptomatic requiring management with drug therapies and elec- trophysiological procedures. The European Society of Cardiology published management guidelines for supraventricular tachycardias Abbreviations (SVT) in 2003,1 and corresponding US guidelines have also been published, the most recent being in 2015.2 AAD: antiarrhythmic drugs There is a need to provide expert recommendations for profes- ACHD: adult congenital heart disease sionals participating in the care of patients presenting with SVT. In AF: atrial fibrillation addition, several associated conditions where SVTs may co-exist AFL: atrial flutter need to be explained in more detail. To address this topic, a Task ANP: atrial natriuretic peptide Force was convened by the European Heart Rhythm Association AP: accessory pathway (EHRA) with representation from the Heart Rhythm Society ASD: atrial septal defect (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Downloaded from AV: atrioventricular Latinoamericana de Estimulacio´n Cardiaca y Electrofisiologia (SO- AVN: atrioventricular node LAECE), with the remit to comprehensively review the published AVNRT: atrioventricular nodal reentrant tachycardia evidence available, and to publish a joint consensus document on by guest on November 20, 2016 AVRT: atrioventricular reentrant tachycardia the management of SVT patients, with up-to-date consensus recom- AT: atrial tachycardia mendations for clinical practice. BBB: bundle branch block This document summarizes current developments in the field, bpm: beats per minute with focus on new advances since the last ESC guidelines, and pro- CI: confidence interval vides general recommendations for the management of SVT pa- CL: cycle length tients based on the principles of evidence-based medicine. CTI: cavo-tricuspid isthmus DC: direct current Evidence review ECG: electrocardiogram Members of the Task Force were asked to perform a detailed litera- EPS: electrophysiology study ture review, weigh the strength of evidence for or against a particu- ERP: effective refractory period lar treatment or procedure, and include estimates of expected HPS: His-Purkinje system health outcomes where data exist. Patient-specific modifiers, co- HR: heart rate morbidities, and issues of patient preference that might influence IV: intravenous the choice of particular tests or therapies are considered, as are fre- IVC: inferior vena cava quency of follow-up and cost-effectiveness. In controversial areas, LA: left atrium or with regard to issues without evidence other than usual clinical LBBB: left bundle branch block practice, a consensus was achieved by agreement of the expert pa- LV: left ventricle nel after thorough deliberations. This document was prepared by MESA: Marshfield (Wisconsin) Epidemiologic Study Area the Task Force with representation from EHRA, HRS, APHRS, MRT: macroreentrant tachycardia and SOLAECE. The document was peer-reviewed by official exter- ms: milliseconds nal reviewers representing EHRA, HRS, APHRS, and SOLAECE. PJRT: permanent junctional reciprocating tachycardia Consensus statements are evidence-based, and derived primarily POTS: postural orthostatic tachycardia syndrome from published data. Current systems of ranking level of evidence PPI: post-pacing interval are becoming complicated in a way that their practical utility might QALY: quality-adjusted life years be compromised.3 We have, therefore, opted for an easier and, QoL: quality of life perhaps, more user-friendly system of ranking that should allow RA: right atrium physicians to easily assess current status of evidence and conse- RBBB: right bundle branch block quent guidance (Table 1). Thus, a green heart indicates a recom- RCT: randomized controlled trials mended/indicated treatment or procedure and is based on at least RF: radiofrequency one randomized trial, or is supported by strong observational EHRA consensus document on the management of SVT Page 3 of 47 Table 1 Scientific rationale of recommendations Table 2 Conventional classification of supraventricular tachycardias Scientific evidence that a treatment or Recommended/ procedure is beneficial and effective. indicated Atrial tachycardias Requires at least one randomized Sinus tachycardia trial, or is supported by strong observational evidence and authors’ Physiological sinus tachycardia consensus. Inappropriate sinus tachycardia General agreement and/or scientific May be used or Sinus node reentrant tachycardia