Supraventricular Tachycardia Clinical Practice ESC Guidelines
For conversion of atrial flutter:
Intravenous (IV) ibutilide, or
IV or oral (PO) (in-hospital) dofetilide
For Termination of Atrial Flutter
(when implanted pacemaker or defibrillator is present):
High-rate atrial pacing
For Asymptomatic patients with high-risk features
• Shortest pre-excited RR interval during AF
[SPERRI] ≤250 ms,
• Accessory pathway [AP] effective refractory
period [ERP] ≤250 ms,
• Multiple APs, and
• Inducible AP-mediated tachycardia)
as identified on (EPS) using isoprenaline:
For Tachycardia responsible for
• Tachycardiomyopathy that cannot be ablated
or controlled by drugs:
Atrioventricular nodal ablation followed by pacing
“ablate and pace”(biventricular or His-bundle pacing)
First trimester of pregnancy:
Avoid all antiarrhythmic drugs, if possible
Class IIa (should be considered)
Symptomatic patients with inappropriate sinus tachycardia:
Consider ivabradine alone or with a beta-blocker
Atrial flutter without atrial fibrillation:
(initiation threshold not yet established)
Consider EPS for risk stratification
Asymptomatic preexcitation with left ventricular dysfunction due to electrical dyssynchrony:
Consider catheter ablation
Class IIb (may be considered)
Acute focal atrial tachycardia:
Consider IV ibutilide
Chronic focal atrial tachycardia:
Consider ivabradine with a beta-blocker
Postural orthostatic tachycardia syndrome:
Consider noninvasive assessment of the AP conducting properties
Asymptomatic preexcitation with low-risk AP at invasive/noninvasive risk stratification:
Consider catheter ablation
Prevention of SVT in pregnant women without Wolff-Parkinson-White syndrome:
Consider beta-1 selective blockers
(except atenolol) (preferred) or verapamil
Prevention of SVT in pregnant women with Wolff-Parkinson-White syndrome and without ischemic or structural heart disease:
Consider flecainide or propafenone
Class III (not recommended)
IV amiodarone is not recommended
for preexcited atrial fibrillation.
Not all SVTs are arrhythmias of the young.
Vagal manoeuvres and adenosine are
the treatments of choice for the acute therapy
of SVT, and may also provide important
Verapamil is not recommended in wide QRS-
complex tachycardia of unknown aetiology.
Consider using ivabradine, when indicated,
together with a beta-blocker.
In all re-entrant and most focal arrhythmias,
catheter ablation should be offered as an initial
choice to patients, after having explained in
detail the potential risks and benefits.
Patients with macro−re-entrant tachycardias
following atrial surgery should be referred to
specialized centres for ablation.
In post-AF ablation ATs, focal or
macro−re-entrant, ablation should be deferred
for ≥3 months after AF ablation, when possible.
Ablate AVNRT, typical or atypical, with lesions in
the anatomical area of the nodal extensions,
either from the right or left septum.
AVNRT, typical or atypical, can now be ablated
with almost no risk of AV block.
Do not use sotalol in patients with SVT.
Do not use flecainide or propafenone in patients
with LBBB, or ischaemic or structural heart disease.
Do not use amiodarone in pre-excited AF.
One in five patients with asymptomatic
pre-excitation will develop an arrhythmia
related to their AP during follow-up.
The risk of cardiac arrest/ventricular fibrillation
in a patient with asymptomatic pre-excitation
is ∼2.4 per 1000 person-years.
Non-invasive screening may be used for risk
stratification of patients with asymptomatic
pre-excitation, but its predictive ability remains modest.
Invasive assessment with an EPS is
recommended in patients with asymptomatic
pre-excitation who either have high-risk
occupations or are competitive athletes.
If a patient undergoes assessment with an EPS
and is found to have an AP with ‘high-risk’
characteristics, catheter ablation should
If possible, avoid all antiarrhythmic drugs during
the first trimester of pregnancy. If beta-blockers
are necessary, use only beta-1 selective agents
(but not atenolol).
If ablation is necessary during pregnancy,
use non-fluoroscopic mapping.
Consider TCM in patients with reduced
LV function and SVT.
Ablation is the treatment of choice for TCM
due to SVT. AV nodal ablation with subsequent
biventricular or His-bundle pacing
(‘ablate and pace’) should be considered if
the SVT cannot be ablated.