Supraventricular Tachycardia Clinical Practice ESC Guidelines

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:

👉Catheter ablation

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

2️⃣ Class IIa (should be considered)


Symptomatic patients with inappropriate sinus tachycardia:

👉Consider ivabradine alone or with a beta-blocker

Atrial flutter without atrial fibrillation:

👉Consider anticoagulation

(initiation threshold not yet established)

Asymptomatic preexcitation:

👉Consider EPS for risk stratification

Asymptomatic preexcitation with left ventricular dysfunction due to electrical dyssynchrony:

👉Consider catheter ablation

2️⃣ 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 ivabradine

Asymptomatic preexcitation:

👉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

3️⃣ Class III (not recommended)


👉IV amiodarone is not recommended

for preexcited atrial fibrillation.

📩 Key 🔑 Messages


©️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

diagnostic information.

©️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.