Acute Treatment of Patients With Supraventricular Tachycardia
Sana M. Al-Khatib, MD, MHS1; Richard L. Page, MD2
Author Affiliations Article Information
JAMA Cardiol. 2016;1(4):483-485. doi:10.1001/jamacardio.2016.1483
Guideline title: 2015 American College of Cardiology/American Heart Association/Heart Rhythm Society Guideline for the Management of Adult Patients With Supraventricular Tachycardia

Developers: American College of Cardiology, American Heart Association, and Heart Rhythm Society

Release dates: September 23, 2015 (online); April 5, 2016 (print)

Prior version: October 14, 2003

Funding sources: American College of Cardiology, American Heart Association, and Heart Rhythm Society

Target population: Adults with supraventricular tachycardia (SVT)

Major recommendations: This guideline offers recommendations for the management of SVT. Atrial fibrillation was not covered. This synopsis summarizes recommendations on the acute management of SVT.

Vagal maneuvers and adenosine are recommended (moderate-quality evidence) for the termination of regular SVT of uncertain type, atrioventricular nodal reentrant tachycardia, and atrioventricular reentrant tachycardia.

Synchronized cardioversion is recommended (moderate-quality evidence) for the termination of any hemodynamically unstable SVT.

In the absence of hemodynamic compromise, SVT should be treated (moderate-quality evidence) with synchronized cardioversion when pharmacologic therapy is ineffective or contraindicated.

Intravenous diltiazem, verapamil, or metoprolol is recommended for control of heat rate in patients with hemodynamically stable atrial flutter (moderate-quality evidence) and for the treatment of hemodynamically stable focal atrial tachycardia (low-quality evidence).

Intravenous diltiazem, verapamil, or metoprolol can be useful in terminating hemodynamically stable regular SVT of uncertain type (moderate-quality evidence for diltiazem and verapamil and low-quality evidence for β-blockers), multifocal atrial tachycardia (low-quality evidence for metoprolol and verapamil and none for diltiazem), atrioventricular nodal reentrant tachycardia (moderate-quality evidence for all), and orthodromic atrioventricular reentrant tachycardia in the absence of pre-excitation on the resting electrocardiogram (moderate-quality evidence for diltiazem and verapamil and low-quality evidence for β-blockers).

Anticoagulation is recommended (moderate-quality evidence) in patients with atrial flutter to mirror recommended anticoagulation for patients with atrial fibrillation.

Treatment of pre-excited atrial fibrillation with intravenous digoxin, intravenous amiodarone, intravenous or oral β-blockers, diltiazem, and verapamil is potentially harmful (low-quality evidence). Instead, intravenous ibutilide or procainamide is recommended (low-quality evidence) for the treatment of hemodynamically stable pre-excited atrial fibrillation.

Summary of the Clinical Problem
Supraventricular tachycardia (SVT) is relatively common in adult Americans, with 89 000 newly diagnosed cases each year and a prevalence of 570 000 persons.1 Supraventricular tachycardia accounts for approximately 50 000 emergency department visits each year.1 The manifestations of SVT vary widely, from total lack of symptoms to debilitating symptoms with substantial effects on patient functional status and quality of life.

Clinicians should be able to recognize SVT when they detect regular narrow complex tachycardia and should know how to treat patients with SVT. Key steps in the assessment and treatment of patients with SVT are determining whether a patient is hemodynamically stable and deciding whether any symptoms reported by the patient are indeed owing to the SVT. Another important step is to try to establish the mechanism of the tachycardia because this will help inform the best treatment course. Finally, it is critically important to review the patient’s medical history to discover any potential contraindications to therapies that could be administered in these settings (Figure).2,3

Characteristics of the Guideline Source
This guideline was developed by the American College of Cardiology, the American Heart Association, and the Heart Rhythm Society.2 The guideline writing committee included 17 members: 14 adult electrophysiologists, 1 pediatric electrophysiologist, 1 general cardiologist, and 1 patient/consumer representative. The development of recommendations was based on all available evidence, with literature searches focusing on randomized clinical trials, registries, nonrandomized comparative and descriptive studies, and systematic reviews.

The rigor of each recommendation in the guideline document was designated by a class of recommendation and a level of evidence (LOE).4 The class of recommendation is a measure of the strength the guideline writing committee assigns to the recommendation when examining the expected magnitude and certainty of benefit in proportion to risk. The class of recommendation can be class I, indicating that the benefit of the intervention far exceeds the risk; class IIa, indicating that the benefit of the intervention moderately exceeds the risk; class IIb, indicating that the benefit may not exceed the risk; and class III, indicating that the benefit is equivalent to or is exceeded by the risk. The LOE can be A (evidence from high-quality randomized clinical trials), B-R (evidence from moderate-quality randomized clinical trials), B-NR (evidence from well-designed nonrandomized studies), C (evidence from randomized or nonrandomized studies with limitations), or E (expert opinion).4

The chair and most guideline writing committee members had to have no relevant relations with industry.

Evidence Base
For the termination of SVT, the guideline addressed the following interventions: vagal maneuvers, adenosine, synchronized cardioversion, β-blockers, calcium-channel blockers, digoxin, antiarrhythmic medications (such as ibutilide and amiodarone), and rapid atrial pacing. The published literature was reviewed extensively through September 2014. Studies were reviewed if they involved human participants, were published in English, and indexed in Medline (through PubMed), Embase, the Cochrane Library, or the Agency for Healthcare Research and Quality. For each clinical question, all studies generated by the literature search were systematically reviewed. Of the nearly 450 studies reviewed, only 4 were randomized clinical trials, and the rest were primarily observational studies.3

Of the 36 recommendations involving the management of SVT, 25 were class I recommendations, 10 were class IIa recommendations, 0 were class IIb recommendations, and 1 was a class III recommendation. Of the 25 class I recommendations, 1 had an LOE A, 7 had an LOE B-R, 10 had an LOE B-NR, 7 had an LOE C, and none had an LOE E.

Benefits and Harms
The potential benefits and harms of each intervention were carefully considered. Interventions used for the termination of SVT are generally safe as long as no contraindications exist. For example, β-blockers and calcium-channel blockers should not be given in the presence of hypotension. The 1 recommendation involving harm was related to giving digoxin, amiodarone, β-blockers, or calcium-channel blockers for pre-excited atrial fibrillation.

Discussion
In developing this guideline document, high-quality evidence was unavailable for many of the recommendations. Reasons for the lack of high-quality evidence are several and include the longstanding use of the current interventions and the favorable safety profile of most interventions that make it almost impossible to study these interventions in contemporary randomized clinical trials. However, the guideline is based on the strongest available evidence and is helpful in guiding treatment options for the termination of SVT.

Areas in Need of Future Study or Ongoing Research
New medications for the termination of SVT are needed, and studies that can elucidate the best drug for each individual patient are necessary. In that regard, it is particularly important to generate evidence on the best treatment approaches to older patients and pregnant women. The best treatments for less common types of SVT, such as junctional tachycardia, should be defined. Finally, more studies should examine patient-centered outcomes and cost-effectiveness data.

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Article Information
Corresponding Author: Sana M. Al-Khatib, MD, MHS, Duke Clinical Research Institute, Division of Cardiology, Duke University Hospital, 2400 Pratt St, Durham, NC 27705 (alkha001@mc.duke.edu).

Published Online: June 8, 2016. doi:10.1001/jamacardio.2016.1483.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

References
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