Guideline sources The following summarized guidelines for the management of orthodromic atrioventricular reentrant tachycardia 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. Medical management Acute management: Administer intravenous adenosine (8-18 mg bolus) for acute management of hemodynamically stable patients with orthodromic AVRT if vagal maneuvers fail. B Consider administering IV formulations of the following medications for acute management of hemodynamically stable patients with orthodromic AVRT if vagal maneuvers and adenosine fail: nondihydropyridine CCBs, i.e. verapamil or diltiazem C https://web.pathway.md/diseases/recDZ99xqUR7Nlr5A 1/3 6/30/23, 1:23 AM Orthodromic atrioventricular reentrant tachycardia Pathway -blockers, i.e. esmolol or metoprolol in the absence of decompensated HF. C Administer adenosine for acute management of patients with orthodromic AVRT. B Show 4 more Ongoing management: Consider initiating the following medications for the management of patients with orthodromic AVRT and without signs of pre-excitation on resting ECG, if ablation is not desirable or feasible: -blockers nondihydropyridine CCBs (verapamil or diltiazem) in the absence of HFrEF. (Class IIa, Level B) consider initiating the following medications for the management of patients with orthodromic AVRT and without ischemic or structural heart disease, if ablation is not desirable or feasible: propafenone flecainide. C Do not use the following medications in patients with pre-excited AF: -blockers nondihydropyridine CCBs (verapamil or diltiazem) digoxin amiodarone. D Initiate oral formulations of the following medications for ongoing management of patients with AVRT and without pre-excitation on their resting ECG: -blockers diltiazem verapamil. B Show 6 more 2. Nonpharmacologic interventions Vagal maneuvers: Perform vagal maneuvers, preferably in the supine position with leg elevation, for acute management of hemodynamically stable patients with orthodromic AVRT. B Perform vagal maneuvers for acute management of patients with orthodromic AVRT. B 3. Therapeutic procedures Synchronized electrical cardioversion: As per ESC 2020 guidelines: Perform synchronized direct current cardioversion for acute management of hemodynamically unstable patients with orthodromic AVRT. B https://web.pathway.md/diseases/recDZ99xqUR7Nlr5A 2/3 6/30/23, 1:23 AM Orthodromic atrioventricular reentrant tachycardia Pathway Perform synchronized direct current cardioversion for acute management of hemodynamically stable patients with orthodromic AVRT if drug therapy fails to convert or control the tachycardia. B Perform synchronized cardioversion for acute management of hemodynamically unstable patients with atrioventricular re-entrant tachycardia if vagal maneuvers or adenosine are ineffective or not feasible. B Show 2 more Catheter ablation: Perform catheter ablation of accessory pathways in patients with symptomatic, recurrent orthodromic AVRT. B Perform catheter ablation of the accessory pathway in patients with AVRT and/or pre-excited AF. B Clinical findings Symptoms Vital signs Chest pain Tachycardia Dizziness ECG findings Lightheadedness Palpitations P wave inversion Pre-syncope Prolonged RP interval Shortness of breath Qrs alternans Syncope St-segment depression QRS duration Integument exam RP interval Diaphoresis References 1. 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 2. 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 https://web.pathway.md/diseases/recDZ99xqUR7Nlr5A 3/3