Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

unstable: BP <90/60 mmHg, signs of systemic hypoperfusion or unstable atrial fibrillation

1st line – direct-current (DC) cardioversion

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INITIAL
|
unstable: BP <90/60 mmHg, signs of systemic hypoperfusion or unstable atrial fibrillation
1st line – 

direct-current (DC) cardioversion

Patients with an acute tachycardia and who are haemodynamically unstable (BP <90/60 mmHg, with signs of systemic hypoperfusion) or who have atrial fibrillation with >250 bpm, or in whom the atrial fibrillation has degenerated to ventricular fibrillation, require immediate DC cardioversion.

A 50- to 360-J biphasic synchronised DC shock can be used (commonly the initial cardioversion is attempted with 50 J for supraventricular tachycardia, but up to 360 J may be needed for cardioversion of atrial fibrillation with rapid ventricular response). DC cardioversion without the synchronised mode can induce ventricular fibrillation.

Conscious sedation (e.g., with intravenous propofol) is also required.

ACUTE

stable: narrow complex (orthodromic atrioventricular reciprocating) tachycardia

1st line – carotid sinus massage or Valsalva manoeuvre

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ACUTE
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stable: narrow complex (orthodromic atrioventricular reciprocating) tachycardia
1st line – 

carotid sinus massage or Valsalva manoeuvre

Because orthodromic reciprocating tachycardia involves the atrioventricular (AV) node as one limb of the circus movement tachycardia, any manoeuvre or drug that slows or interrupts conduction in the AV node can terminate the tachycardia. In a haemodynamically stable patient, vagal manoeuvres such as a carotid sinus massage should be performed at the bedside, or, alternatively, patients can be instructed to perform a Valsalva manoeuvre to terminate the arrhythmia.

2nd line – intravenous adenosine or atrioventricular (AV) nodal blocking drugs or anti-arrhythmics

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ACUTE
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stable: narrow complex (orthodromic atrioventricular reciprocating) tachycardia
2nd line – 

intravenous adenosine or atrioventricular (AV) nodal blocking drugs or anti-arrhythmics

Adenosine is preferred because of its ultra-short half life (<18 seconds). It should be given as a rapid intravenous injection in a central vein or in the antecubital vein, followed by 10-20 mL of rapid normal saline flush. It can be used a second time if there is no response.

Adenosine injection may cause chest pain, chest tightness, bronchospasm, dizziness, and a short run of atrial fibrillation (1% to 15%). Although atrial fibrillation is usually transient, it can cause rapid conduction to the ventricle via the accessory pathway, and if the conduction is rapid then it can potentially result in ventricular fibrillation. Therefore, resuscitation equipment should be available as a standby. Adenosine should be avoided in patients with severe asthma and patients with a known hypersensitivity to the drug. In addition, adenosine injection is associated with a higher risk of heart block in patients on carbamazepine therapy.

AV nodal blocking drugs (diltiazem, verapamil, metoprolol) can be used when there is no response or a recurrence after carotid sinus massage and adenosine.

Anti-arrhythmic drugs (procainamide, ibutilide, amiodarone, flecainide) can be used when there is no response or a recurrence after carotid sinus massage, adenosine, and AV nodal blocking drugs.

Primary options

adenosine: 6 mg intravenously initially, followed by 12 mg intravenously in 1-2 minutes if required

Secondary options

diltiazem: 0.25 mg/kg (average adult dose 20 mg) intravenously initially, followed by 0.35 mg/kg (average adult dose 25 mg) intravenously in 15 minutes if required

OR

verapamil: 2.5 to 5 mg intravenously initially, followed by 5-10 mg (or 0.15 mg/kg) intravenously in 15-30 minutes if required, maximum 30 mg/total dose

OR

metoprolol: 2.5 to 5 mg intravenously every 2-5 minutes as needed, maximum 15 mg/total dose

Tertiary options

procainamide: 100 mg intravenously every 5 minutes as needed, maximum 1000 mg/total dose

OR

ibutilide: <60 kg body-weight: 0.01 mg/kg intravenously initially, followed by 0.01 mg/kg intravenously in 10 minutes if required; ≥60 kg body-weight: 1 mg intravenously initially, followed by 1 mg intravenously in 10 minutes if required

OR

amiodarone: 150 mg intravenously initially, followed by 0.5 to 1 mg/minute intravenous infusion if needed

OR

flecainide: 2 mg/kg (maximum 150 mg/dose) intravenously initially, followed by 1.5 mg/kg/hour for 1 hour if needed, then 0.1 to 0.25 mg/kg/hour for up to 24 hours if needed, maximum 600 mg/day

3rd line – rapid atrial pacing

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ACUTE
|
stable: narrow complex (orthodromic atrioventricular reciprocating) tachycardia
3rd line – 

rapid atrial pacing

Rapid atrial pacing using a temporary pacemaker for overdrive suppression of the tachycardia can be used if previous drug treatments fail.

4th line – direct-current (DC) cardioversion

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ACUTE
|
stable: narrow complex (orthodromic atrioventricular reciprocating) tachycardia
4th line – 

direct-current (DC) cardioversion

In patients whose symptoms persist despite pharmacotherapy or atrial pacing, DC cardioconversion should be used.

A 50- to 360-J biphasic synchronised DC shock can be used (commonly the initial cardioversion is attempted with 50 J for supraventricular tachycardia, but up to 360 J may be needed for cardioversion of atrial fibrillation with rapid ventricular response). DC cardioversion without the synchronised mode can induce ventricular fibrillation.

Conscious sedation (e.g., with intravenous propofol) is also required.

stable: wide complex (antidromic atrioventricular reciprocating) tachycardia

1st line – intravenous adenosine or anti-arrhythmics

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ACUTE
|
stable: wide complex (antidromic atrioventricular reciprocating) tachycardia
1st line – 

intravenous adenosine or anti-arrhythmics

If the tachycardia is haemodynamically stable, then management is with intravenous adenosine or anti-arrhythmic drugs.

Adenosine is preferred because of its ultra-short half life (<18 seconds). It should be given as a rapid intravenous injection in a central vein or in the antecubital vein, followed by 10-20 mL of rapid normal saline flush. It can be used a second time if there is no response.

Adenosine injection may cause chest pain, chest tightness, bronchospasm, dizziness, and a short run of atrial fibrillation (1% to 15%). Although atrial fibrillation is usually transient, it can cause rapid conduction to the ventricle via the accessory pathway, and if the conduction is rapid then it can potentially result in ventricular fibrillation. Therefore, resuscitation equipment should be available as a standby. Adenosine should be avoided in patients with severe asthma and patients with a known hypersensitivity to the drug. In addition, adenosine injection is associated with a higher risk of heart block in patients on carbamazepine therapy.

Anti-arrhythmic drugs (procainamide, ibutilide, amiodarone, flecainide) can also be used when there is no response or a recurrence after adenosine.

Calcium channel blockers, digoxin, and beta-blockers are contraindicated in this population, because these drugs slow the conduction via the atrioventricular node but do not have any effect on the accessory pathway. This may result in a rapid conduction via the accessory pathway, which may cause ventricular tachycardia and ventricular fibrillation leading to sudden cardiac death.

Primary options

adenosine: 6 mg intravenously initially, followed by 12 mg intravenously in 1-2 minutes if required

Secondary options

procainamide: 100 mg intravenously every 5 minutes as needed, maximum 1000 mg/total dose

OR

ibutilide: <60 kg body-weight: 0.01 mg/kg intravenously initially, followed by 0.01 mg/kg intravenously in 10 minutes if required; ≥60 kg body-weight: 1 mg intravenously initially, followed by 1 mg intravenously in 10 minutes if required

OR

amiodarone: 150 mg intravenously initially, followed by 0.5 to 1 mg/minute intravenous infusion if needed

OR

flecainide: 2 mg/kg (maximum 150 mg/dose) intravenously initially, followed by 1.5 mg/kg/hour for 1 hour if needed, then 0.1 to 0.25 mg/kg/hour for up to 24 hours if needed, maximum 600 mg/day

2nd line – rapid atrial pacing

Back
ACUTE
|
stable: wide complex (antidromic atrioventricular reciprocating) tachycardia
2nd line – 

rapid atrial pacing

Rapid atrial pacing using a temporary pacemaker for overdrive suppression of the tachycardia can be used if previous drug treatments fail.

3rd line – direct-current (DC) cardioversion

Back
ACUTE
|
stable: wide complex (antidromic atrioventricular reciprocating) tachycardia
3rd line – 

direct-current (DC) cardioversion

In patients whose symptoms persist despite pharmacotherapy or atrial pacing, DC cardioconversion should be used.

A 50- to 360-J biphasic synchronised DC shock can be used (commonly the initial cardioversion is attempted with 50 J for supraventricular tachycardia, but up to 360 J may be needed for cardioversion of atrial fibrillation with rapid ventricular response). DC cardioversion without the synchronised mode can induce ventricular fibrillation.

Conscious sedation (e.g., with intravenous propofol) is also required.

stable: pre-excited tachycardia due to atrial fibrillation or atrial flutter

1st line – anti-arrhythmics + consider anticoagulation

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ACUTE
|
stable: pre-excited tachycardia due to atrial fibrillation or atrial flutter
1st line – 

anti-arrhythmics + consider anticoagulation

Pre-excited tachycardia results in a rapid irregular wide complex tachycardia with varying duration and amplitude of QRS complexes depending upon the degree of pre-excitation.

Intravenous infusions of anti-arrhythmic drugs such as procainamide, ibutilide, or flecainide, which prevent rapid conduction through the accessory pathway, are used, even though they may not be able to terminate the atrial arrhythmia.​[3][20]

Anticoagulation should be considered in atrial fibrillation and atrial flutter depending on presence of comorbid cardiological abnormalities and duration of onset.

Primary options

procainamide: 100 mg intravenously every 5 minutes as needed, maximum 1000 mg/total dose

OR

ibutilide: <60 kg body-weight: 0.01 mg/kg intravenously initially, followed by 0.01 mg/kg intravenously in 10 minutes if required; ≥60 kg body-weight: 1 mg intravenously initially, followed by 1 mg intravenously in 10 minutes if required

OR

flecainide: 2 mg/kg (maximum 150 mg/dose) intravenously initially, followed by 1.5 mg/kg/hour for 1 hour if needed, then 0.1 to 0.25 mg/kg/hour for up to 24 hours if needed, maximum 600 mg/day

2nd line – rapid atrial pacing (for atrial flutter)

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ACUTE
|
stable: pre-excited tachycardia due to atrial fibrillation or atrial flutter
2nd line – 

rapid atrial pacing (for atrial flutter)

In patients with atrial flutter, rapid atrial pacing using a temporary pacemaker for overdrive suppression of the atrial flutter can be used if previous drug treatments fail.

Rapid atrial pacing has no role in atrial fibrillation.

2nd line – direct-current (DC) cardioversion

Back
ACUTE
|
stable: pre-excited tachycardia due to atrial fibrillation or atrial flutter
2nd line – 

direct-current (DC) cardioversion

In patients with atrial fibrillation or atrial flutter whose symptoms persist despite anti-arrhythmic agents, DC cardioconversion should be used.

A 50- to 360-J biphasic synchronised DC shock can be used (commonly the initial cardioversion is attempted with 50 J for supraventricular tachycardia, but up to 360 J may be needed for cardioversion of atrial fibrillation with rapid ventricular response). DC cardioversion without the synchronised mode can induce ventricular fibrillation.

Conscious sedation (e.g., with intravenous propofol) is also required.

stable: pre-excited tachycardia due to atrial tachycardia

1st line – anti-arrhythmics

Back
ACUTE
|
stable: pre-excited tachycardia due to atrial tachycardia
1st line – 

anti-arrhythmics

Pre-excited tachycardia results in a rapid irregular wide complex tachycardia with varying duration and amplitude of QRS complexes depending upon the degree of pre-excitation.

Intravenous infusions of anti-arrhythmic drugs such as procainamide, ibutilide, flecainide, or amiodarone, which prevent rapid conduction through the accessory pathway, are used, even though they may not be able to terminate the atrial arrhythmia.[3]​​[20]

Primary options

procainamide: 100 mg intravenously every 5 minutes as needed, maximum 1000 mg/total dose

OR

ibutilide: <60 kg body-weight: 0.01 mg/kg intravenously initially, followed by 0.01 mg/kg intravenously in 10 minutes if required; ≥60 kg body-weight: 1 mg intravenously initially, followed by 1 mg intravenously in 10 minutes if required

OR

amiodarone: 150 mg intravenously initially, followed by 0.5 to 1 mg/minute intravenous infusion if needed

OR

flecainide: 2 mg/kg (maximum 150 mg/dose) intravenously initially, followed by 1.5 mg/kg/hour for 1 hour if needed, then 0.1 to 0.25 mg/kg/hour for up to 24 hours if needed, maximum 600 mg/day

2nd line – rapid atrial pacing

Back
ACUTE
|
stable: pre-excited tachycardia due to atrial tachycardia
2nd line – 

rapid atrial pacing

Rapid atrial pacing using a temporary pacemaker for overdrive suppression of the atrial tachycardia can be used if previous drug treatments fail.

3rd line – direct-current (DC) cardioversion

Back
ACUTE
|
stable: pre-excited tachycardia due to atrial tachycardia
3rd line – 

direct-current (DC) cardioversion

In patients with atrial tachycardia whose symptoms persist despite anti-arrhythmic agents or atrial pacing, DC cardioconversion should be used.

A 50- to 360-J biphasic synchronised DC shock can be used (commonly the initial cardioversion is attempted with 50 J for supraventricular tachycardia, but up to 360 J may be needed for cardioversion of atrial fibrillation with rapid ventricular response). DC cardioversion without the synchronised mode can induce ventricular fibrillation.

Conscious sedation (e.g., with intravenous propofol) is also required.

However, the recurrence of atrial arrhythmia after DC cardioversion may be higher in atrial tachycardia, compared with atrial fibrillation/flutter, depending on the mechanism. If the atrial tachycardia is related to abnormal automaticity, DC cardioversion may not be effective at all, such as in multifocal atrial tachycardia.

ONGOING

following acute treatment: asymptomatic

1st line – risk stratification and monitoring

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ONGOING
|
following acute treatment: asymptomatic
1st line – 

risk stratification and monitoring

While controversy exists, most experts recommend that all patients with ventricular pre-excitation undergo risk stratification to determine their risk of sudden cardiac death, regardless of the presence of symptoms.[15][16][21]

Consider – catheter ablation

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ONGOING
|
following acute treatment: asymptomatic
Consider – 

catheter ablation

Additional treatment recommended for SOME patients in selected patient group

Asymptomatic patients in specialised jobs with particular safety issues (e.g., airline pilot, school bus driver) can be considered for catheter ablation. Catheter ablation is also performed in asymptomatic patients who are found to have a 'high-risk' accessory pathway at the time of electrophysiology testing, showing high-risk antegrade conduction characteristics.[3]​​[20]

Catheter ablation is generally not performed in pregnant patients and should be deferred until after delivery.

following acute treatment: symptomatic

1st line – catheter ablation

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ONGOING
|
following acute treatment: symptomatic
1st line – 

catheter ablation

All patients should be offered catheter ablation.

The incidence of symptomatic tachycardia is reported to be higher during pregnancy, which may be refractory to drugs that are safe to use in such circumstances. Therefore a radiofrequency ablation should be considered prior to the next planned pregnancy. Catheter ablation is generally not performed in pregnant patients and should be deferred until after delivery.

2nd line – anti-arrhythmics

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ONGOING
|
following acute treatment: symptomatic
2nd line – 

anti-arrhythmics

Used in patients who refuse ablation or in whom ablation is unsuitable.

Class I anti-arrhythmic agents (flecainide or propafenone) are suitable for patients with no additional cardiac disease but cannot be used in people with coronary artery disease or structural heart disease.

In patients with coronary artery disease or structural heart disease, class III anti-arrhythmic agents (sotalol, amiodarone, or dofetilide) may be used.

In the event a patient with WPW syndrome becomes pregnant prior to ablation of their accessory pathway, and if frequent recurrences of SVT are observed during pregnancy, it is reasonable to treat the patients with flecainide or propafenone.[3]

QT interval must be determined prior to starting therapy with dofetilide as it is contraindicated if QTc is >440 msec (>500 msec in patients with ventricular conduction abnormalities).

Primary options

flecainide: 50-150 mg orally twice daily

OR

propafenone: 150-300 mg orally (immediate-release) every 8 hours

OR

sotalol: 80-160 mg orally twice daily

OR

amiodarone: 600-800 mg/day orally given in 2 divided doses as a loading dose for 2 weeks, followed by maintenance dose of 200-400 mg/day

OR

dofetilide: 125-500 micrograms orally twice daily

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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