Guideline sources The following summarized guidelines for the evaluation and management of supraventricular tachyarrhythmias are prepared by our editorial team based on guidelines from the European Society of Cardiology (ESC 2020) and the American Heart Association (AHA/HRS/ACC 2016). 1 2 Calculator NYHA functional classification f Guidelines 1. Diagnostic investigations Electrophysiology study: conduct an electrophysiology study with the option of ablation for the diagnosis and potential treatment of patients with supraVT. B https://web.pathway.md/diseases/reclT9ME6pNHBf7m3 1/4 6/24/23, 3:14 PM Supraventricular tachyarrhythmias Pathway Electrocardiography: obtain a 12-lead ECG during tachycardia during acute management of hemodynamically stable patients with either narrow or wide QRS tachycardia in the absence of an established diagnosis. B 2. Medical management Acute management: Administer intravenous adenosine (6-18 mg bolus) for acute management of hemodynamically stable patients with narrow QRS tachycardia, if vagal maneuvers fail, in the absence of an established diagnosis. B Show 4 more Administer adenosine for acute management of patients with regular supraVT. B Show 2 more Ongoing management: Initiate oral formulations of the following medications for ongoing management of patients with symptomatic supraVT not having ventricular pre-excitation during sinus rhythm: -blockers diltiazem verapamil. B Show 5 more 3. Nonpharmacologic interventions Vagal maneuvers: Perform vagal maneuvers, preferably in the supine position with leg elevation, for acute management of hemodynamically stable patients with narrow QRS tachycardia in the absence of an established diagnosis. B Perform vagal maneuvers for acute management of hemodynamically stable patients with wide QRS tachycardia in the absence of an established diagnosis. B Perform vagal maneuvers for acute management of patients with regular supraVT. B 4. Therapeutic procedures Synchronized electrical cardioversion: Perform synchronized direct current cardioversion for acute management of hemodynamically unstable patients with either narrow or wide QRS tachycardia in the absence of an established diagnosis. B Perform synchronized direct current cardioversion for acute management of hemodynamically stable patients with either narrow or wide QRS tachycardia, if medical therapy fails to convert or control the tachycardia, in the absence of an established diagnosis. B https://web.pathway.md/diseases/reclT9ME6pNHBf7m3 2/4 6/24/23, 3:14 PM Supraventricular tachyarrhythmias Pathway Perform synchronized cardioversion for acute management of patients with hemodynamically unstable supraVT when vagal maneuvers or adenosine are ineffective or not feasible. B Perform synchronized cardioversion for acute management of patients with hemodynamically stable supraVT when pharmacological therapy is ineffective or contraindicated. B 5. Specific circumstances Patients with congenital heart disease, acute management: As per ESC 2020 guidelines, perform vagal maneuvers, preferably in the supine position with leg elevation, for acute management of hemodynamically stable adult patients with supraVT and congenital heart disease. B Show 4 more As per ACC/AHA/HRS 2016 guidelines, administer IV adenosine for acute management of adult patients with congenital heart disease and supraVT. B Show 7 more Patients with congenital heart disease, ongoing management: As per ESC 2020 guidelines, consider initiating -blockers for the management of patients with recurrent focal AT or atrial flutter and congenital heart disease, if ablation is not possible or successful. C Show 5 more As per ACC/AHA/HRS 2016 guidelines, assess for associated hemodynamic abnormalities for potential repair of structural defects in adult patients with congenital heart disease as part of therapy for supraVT. B Show 9 more Patients with tachycardiomyopathy: suspect tachycardiomyopathy in patients with reduced LV ejection fraction with an elevated HR (> 100 bpm). B Show 4 more Pregnant patients, acute management: As per ESC 2020 guidelines, perform vagal maneuvers for acute conversion in pregnant patients with supraVT. B Show 5 more As per ACC/AHA/HRS 2016 guidelines, perform vagal maneuvers for acute management of pregnant patients with supraVT. B Show 6 more Pregnant patients, ongoing management: As per ESC 2020 guidelines, perform catheter ablation in symptomatic patients with recurrent supraVT planning pregnancy. B Show 7 more As per ACC/AHA/HRS 2016 guidelines, consider initiating the following medications, alone or in combination, for ongoing management of pregnant patients with highly symptomatic supraVT: https://web.pathway.md/diseases/reclT9ME6pNHBf7m3 3/4 6/24/23, 3:14 PM Supraventricular tachyarrhythmias Pathway digoxin flecainide metoprolol propafenone propranolol sotalol verapamil. C Show 2 more Older patients: individualize the diagnostic and therapeutic approaches to supraVT in patients > 75 years old to incorporate age, comorbid illness, physical and cognitive functions, patient preferences, and severity of symptoms. B 6. Patient education Patient education: educate patients with supraVT on how to perform vagal maneuvers for ongoing management of supraVT. B References 1. Richard L Page, Jos A Joglar, Mary A Caldwell et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2016 Apr 5;133 14):e471 505. Open 2. Josep Brugada, Demosthenes G Katritsis, Elena Arbelo et al. 2019 ESC Guidelines for the management of patients with supraventricular tachycardia The Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology ESC . Eur Heart J. 2020 Feb 1;41 5 655 720. Open 3. Catherine Ellen Poindexter Professor of Cardiology, Professor of Medicine, Director et al. Guidelines for the management of patients with supraventricular tachycardia. Eur Heart J. 2019 Dec 14;40 47 3812 3813. Open 4. Catherine Ellen Poindexter Professor of Cardiology, Professor of Medicine, Director et al. Guidelines for the management of patients with supraventricular tachycardia. Eur Heart J. 2019 Dec 14;40 47 3812 3813. Open 5. Andrew Appelboam, Adam Reuben, Clifford Mann et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias REVERT a randomised controlled trial. Lancet. 2015 Oct 31;386 10005 1747 53. Open https://web.pathway.md/diseases/reclT9ME6pNHBf7m3 4/4