ACC/AHA/ESC Guidelines For The Management Of Patients With .
2003 by the American College of Cardiology Foundation, the American Heart Association, Inc., and the European Society of CardiologyACC/AHA/ESC PRACTICE GUIDELINES—FULL TEXTACC/AHA/ESC Guidelines for the Management of PatientsWith Supraventricular Arrhythmias*A Report of the American College of Cardiology/American Heart Association Task Forceand the European Society of Cardiology Committee for Practice Guidelines (WritingCommittee to Develop Guidelines for the Management of Patients With SupraventricularArrhythmias)Developed in Collaboration with NASPE-Heart Rhythm SocietyCOMMITTEE MEMBERSCarina Blomström-Lundqvist, MD, PhD, FACC, FESC, Co-ChairMelvin M. Scheinman, MD, FACC, Co-ChairEtienne M. Aliot, MD, FACC, FESCJoseph S. Alpert, MD, FACC, FAHA, FESCHugh Calkins, MD, FACC, FAHAA. John Camm, MD, FACC, FAHA, FESCW. Barton Campbell, MD, FACC, FAHADavid E. Haines, MD, FACCKarl H. Kuck, MD, FACC, FESCBruce B. Lerman, MD, FACCD. Douglas Miller, MD, CM, FACCCharlie Willard Shaeffer, Jr., MD, FACCWilliam G. Stevenson, MD, FACCGordon F. Tomaselli, MD, FACC, FAHATASK FORCE MEMBERSElliott M. Antman, MD, FACC, FAHA, ChairSidney C. Smith, Jr., MD, FACC, FAHA, FESC, Vice ChairJoseph S. Alpert, MD, FACC, FAHA, FESCGabriel Gregoratos, MD, FACC, FAHADavid P. Faxon, MD, FACC, FAHALoren F. Hiratzka, MD, FACC, FAHAValentin Fuster, MD, PhD, FACC, FAHA, FESCSharon Ann Hunt, MD, FACC, FAHARaymond J. Gibbons, MD, FACC, FAHA†‡Alice K. Jacobs, MD, FACC, FAHARichard O. Russell, Jr., MD, FACC, FAHA†ESC COMMITTEE FOR PRACTICE GUIDELINES MEMBERSSilvia G. Priori, MD, PhD, FESC, ChairJean-Jacques Blanc, MD, PhD, FESCAndzrej Budaj, MD, FESCEnrique Fernandez Burgos, MDMartin Cowie, MD, PhD, FESCJaap Willem Deckers, MD, PhD, FESCMaria Angeles Alonso Garcia, MD, FESCWerner W. Klein, MD, FACC, FESC‡John Lekakis, MD, FESCBertil Lindahl, MDGianfranco Mazzotta, MD, FESCJoão Carlos Araujo Morais, MD, FESCAli Oto, MD, FACC, FESCOtto Smiseth, MD, PhD, FESCHans-Joachim Trappe, MD, PhD, FESC*This document does not cover atrial fibrillation, which is covered in theACC/AHA/ESC guidelines on the management of patients with atrial fibrillation found on the ACC, AHA, and ESC Web sites.†Former Task Force Member‡Immediate Past ChairScheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ, Campbell WB,Haines DE, Kuck KH, Lerman BB, Miller DD, Shaeffer CW, Stevenson WG,Tomaselli GF. ACC/AHA/ESC guidelines for the management of patients withsupraventricular arrhythmias: a report of the American College ofCardiology/American Heart Association Task Force on Practice Guidelines andthe European Society of Cardiology Committee for Practice Guidelines(Writing Committee to Develop Guidelines for the Management of PatientsWith Supraventricular Arrhythmias. 2003. American College of CardiologyWeb Site. Available at: /sva index.pdf.This document is available on the World Wide Web sites of the AmericanCollege of Cardiology (www.acc.org), the American Heart Association(www.americanheart.org), and the European Society of Cardiology(www.escardio.org). Single and bulk reprints of both the online full-text guidelines and the published executive summary (published in the October 15, 2003This document was approved by the American College of CardiologyFoundation Board of Trustees in August 2003, by the American HeartAssociation Science Advisory and Coordinating Committee in July 2003, andby the European Society of Cardiology Committee for Practice Guidelines inJuly 2003.When citing this document, the American College of Cardiology Foundation,the American Heart Association, and the European Society of Cardiologyrequest that the following citation format be used: Blomström-Lundqvist C,
2ACC - www.acc.orgAHA - www.americanheart.orgESC - www.escardio.orgBlomström-Lundqvist and Scheinman et al. 2003ACC/AHA/ESC Practice Guidelinesissue of the Journal of the American College of Cardiology, the October 14,2003 issue of Circulation, and the 24/20, October 15, 2003, issue of theEuropean Heart Journal) are available from Elsevier Publishers by calling 44.207.424.4200 or 44.207.424.4389, faxing 44.207.424.4433, or writing toElsevier Publishers Ltd, European Heart Journal, ESC Guidelines - Reprints, 32Jamestown Road, London, NW1 7BY, UK or E-mail gr.davies@elsevier.com.Single copies of the executive summary and the full-text guidelines are alsoavailable by calling 800-253-4636 or writing the American College ofCardiology Foundation, Resource Center, at 9111 Old Georgetown Road,Bethesda, MD 20814-1699. To purchase bulk reprints (specify version andreprint number-executive summary 71-0261 and full-text guideline 71-0262): upto 999 copies, call 800-611-6083 (U.S. only) or fax 413-665-2671; 1 000 ormore copies, call 214-706-1466, fax 214-691-6342; or E-mailpubauth@heart.org.TABLE OF CONTENTSPreamble . 2I. Introduction. 3A. Organization of Committee and Evidence Review.3B. Contents of These Guidelines—Scope.4II. Public Health Considerations and Epidemiology.46. Summary of Management.28E. Focal Atrial Tachycardias.291. Definition and Clinical Presentation.292. Diagnosis.293. Site of Origin and Mechanisms.314. Treatment.315. Multifocal Atrial Tachycardia.33F. Macro–Re-entrant Atrial Tachycardia.331. Isthmus-Dependent Atrial Flutter.332. Non–Cavotricuspid Isthmus-Dependent AtrialFlutter .38VI. Special Circumstances.39A. Pregnancy.391. Acute Conversion of Atrioventricular Node–Dependent Tachycardias.402. Prophylactic Antiarrhythmic Drug Therapy.40B. Supraventricular Tachycardias in Adult Patients WithCongenital Heart Disease.411. Introduction.412. Specific Disorders.41C. Drug-Drug and Drug-Metabolic Interactions.43D. Quality-of-Life and Cost Considerations.44III. General Mechanisms of Supraventricular Arrhythmia.5A. Specialized Atrial Tissue.5B. General Mechanisms.6Appendix 1: Abbreviations.46IV. Clinical Presentation, General Evaluation, andManagement of Patients With SupraventricularArrhythmia .7A. General Evaluation of Patients Without DocumentedArrhythmia.71. Clinical History and Physical Examination.72. Diagnostic Investigations.83. Management.9B. General Evaluation of Patients With DocumentedArrhythmia.91. Diagnostic Evaluation.92. Management.12References.48V. Specific Arrhythmias.14A. Sinus Tachyarrhythmias.141. Physiological Sinus Tachycardia.142. Inappropriate Sinus Tachycardia.163. Postural Orthostatic Tachycardia Syndrome.174. Sinus Node Re-entry Tachycardia.19B. Atrioventricular Nodal Reciprocating Tachycardia.201. Definitions and Clinical Features.202. Acute Treatment.203. Long-Term Pharmacologic Therapy.204. Catheter Ablation.21C. Focal and Nonparoxysmal Junctional Tachycardia.231. Focal Junctional Tachycardia.232. Nonparoxysmal Junctional Tachycardia.23D. Atrioventricular Reciprocating Tachycardia (ExtraNodal Accessory Pathways).251. Sudden Death in WPW Syndrome and RiskStratification.262. Acute Treatment.263. Long-Term Pharmacologic Therapy.264. Catheter Ablation.285. Management of Patients With AsymptomaticAccessory Pathways.28Appendix 2: Peer Reviewers.47PREAMBLEIt is important that the medical profession play a significantrole in critically evaluating the use of diagnostic proceduresand therapies in the management or prevention of diseasestates. Rigorous and expert analysis of the available data documenting relative benefits and risks of those procedures andtherapies can produce helpful guidelines that improve theeffectiveness of care, optimize patient outcomes, and generally have a favorable effect on the overall cost of care byfocusing resources on the most effective strategies.The American College of Cardiology Foundation (ACCF),the American Heart Association (AHA) have jointly engagedin the production of such guidelines in the area of cardiovascular disease since 1980. The ACC/AHA Task Force onPractice Guidelines, whose charge is to develop and revisepractice guidelines for important cardiovascular diseases andprocedures, directs this effort. The Task Force is pleased tohave this guideline cosponsored by the European Society ofCardiology (ESC). Experts in the subject under considerationhave been selected from all three organizations to examinesubject-specific data and write guidelines. The processincludes additional representatives from other medical practitioner and specialty groups when appropriate. Writinggroups are specifically charged to perform a formal literaturereview, weigh the strength of evidence for or against a particular treatment or procedure, and include estimates ofexpected health outcomes where data exist. Patient-specificmodifiers, comorbidities and issues of patient preference thatmight influence the choice of particular tests or therapies are
ACC - www.acc.orgAHA - www.americanheart.orgESC - www.escardio.orgconsidered as well as frequency of follow-up. When available, information from studies on cost is considered, butreview of data on diagnostic or therapeutic efficacy and clinical outcomes is the primary basis for preparing recommendations in these guidelines.The ACC/AHA Task Force on Practice Guidelines and theESC Committee on Practice Guidelines make every effort toavoid any actual or potential conflict of interest that mightarise as a result of an industry relationship or from personalbiases of the writing panel. Specifically, all members of thewriting panel were asked to provide disclosure statements ofall such relationships that might be perceived as real orpotential conflicts of interest. These statements are reportedorally to all members of the writing panel during the firstmeeting and are updated as changes occur.These practice guidelines are intended to assist physiciansin clinical decision making by describing a range of generally acceptable approaches for the diagnosis and managementof supraventricular arrhythmias. These guidelines attempt todefine practices that meet the needs of most patients in mostcircumstances. The ultimate judgment regarding care of aparticular patient must be made by the physician and thepatient in light of all of the circumstances presented by thatpatient. There are circumstances in which deviations fromthese guidelines are appropriate.Elliott M. Antman, MD, FACC, FAHAChair, ACC/AHA Task Force on Practice GuidelinesSilvia G. Priori, MD, PhD, FESCChair, ESC Committee for Practice GuidelinesI. INTRODUCTIONA. Organization of Committee andEvidence ReviewSupraventricular arrhythmias are a group of common rhythmdisturbances. The most common treatment strategies includeantiarrhythmic drug therapy and catheter ablation. Over thelast decade, the latter has been shown to be a highly successful and often curative intervention. With the advent of newtherapeutic interventions and sophisticated mapping tools,even very complex arrhythmias may be cured. To facilitateand optimize the management of patients with supraventricular arrhythmias, the ACCF, the AHA, and the ESC created acommittee to establish guidelines for better management ofthese heterogeneous tachyarrhythmias. This document summarizes the management of patients with supraventriculararrhythmias with recommendations for diagnostic procedures as well as indications for antiarrhythmic drugs and/ornonpharmacologic treatments.The panel was composed of physicians and scientists atuniversity and community hospitals. Members were selectedto represent experts from different European countries andfrom the United States and to include members of associations or working groups whose activities and fields of interest were related to the topic of the writing committee, includ-Blomström-Lundqvist and Scheinman et al. 2003ACC/AHA/ESC Practice Guidelines3ing the ESC Working Groups on Arrhythmias, CardiacPacing, and Grown-Up Congenital Heart Diseases and theNorth American Society of Pacing and Electrophysiology(NASPE-Heart Rhythm Society). The writing committee wascomposed of six members representing the ACCF and theAHA, four members representing the ESC, and one memberrepresenting NASPE. The writing committee was chosen onthe basis of willingness and availability to participate actively in meetings and the production of the final manuscript.Writing groups are specifically charged to perform a formalliterature review, weigh the strength of evidence for oragainst a particular treatment or procedure, and estimateexpected health outcomes where data exist. Patient-specificmodifiers, comorbidities, and issues of patient preferencethat might influence the choice of particular tests or therapiesare considered, as are frequency of follow-up and cost effectiveness. In controversial areas, or with regard to issues without evidence other than usual clinical practice, a consensuswas achieved by agreement of the expert panel after thoroughdeliberations.This document was peer reviewed by two official externalreviewers representing the American College of CardiologyFoundation, two official external reviewers representing theAmerican Heart Association, and two official externalreviewers representing the European Society of Cardiology.The North American Society for Pacing and Electrophysiology-Heart Rhythm Society assigned one organizational reviewer to the guideline. In addition, 37 external content reviewers participated in the review representing theACC/AHA Task Force on Practice Guidelines, the ESCCommittee for Practice Guidelines, the ACCF Electrophysiology Committee, the AHA ECG/ArrhythmiasCommittee, the ESC Working Group on Arrhythmias, andthe ESC Task Force on Grown-Up Congenital Heart Disease.See Appendix 2 for the names of all reviewers.The document was approved for publication by the governing bodies of the ACCF, AHA, and ESC. These guidelineswill be reviewed annually by the ESC and the ACC/AHATask Force on Practice Guidelines and will be consideredcurrent unless they are revised or withdrawn from distribution.The ACC/AHA/ESC Writing Committee to DevelopGuidelines for the Management of Patients WithSupraventricular Tachycardias conducted a comprehensivereview of the relevant literature. Literature searches wereconducted in the following databases: PubMed/Medline,EMBASE, the Cochrane Library (including the CochraneDatabase of Systematic Reviews and the CochraneControlled Trials Registry), and Best Evidence. Searcheswere limited to English language sources and to human subjects. The references selected for this document are exclusively peer-reviewed papers that are representative but notall-inclusive.Recommendations are evidence-based and derived primarily from published data. The level of evidence was ranked asfollows:Level A (highest): derived from multiple randomized clinical trials;
4Blomström-Lundqvist and Scheinman et al. 2003ACC/AHA/ESC Practice GuidelinesLevel B (intermediate): Data are based on a limited numberof randomized trials, nonrandomized studies, or observational registries;Level C (lowest): Primary basis for the recommendationwas expert consensus.Recommendations follow the format of previousACC/AHA guidelines for classifying indications, summarizing both the evidence and expert opinion.Class I: Conditions for which there is evidence and/orgeneral agreement that a given procedure ortreatment is useful and effective.Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion aboutthe usefulness/efficacy of a procedure ortreatment.Class IIa: Weight of evidence or opinion is infavor of usefulness/efficacy.Class IIb: Usefulness/efficacy is less wellestablished by evidence or opinion.Class III: Conditions for which there is evidence and/orgeneral agreement that the procedure ortreatment is not useful/effective and in somecases may be harmful.B. Contents of These Guidelines—ScopeThe purpose of this joint ACC/AHA/ESC document is toprovide clinicians with practical and authoritative guidelinesfor the management and treatment of patients with supraventricular arrhythmias (SVA). These include rhythms emanating from the sinus node, from atrial tissue (atrial flutter), andfrom junctional as well as reciprocating or accessory pathway-mediated tachycardia. This document does not includerecommendations for patients with atrial fibrillation (AF)[see ACC/AHA/ESC Guidelines for the Management ofPatients With Atrial Fibrillation (1)] or for pediatric patientswith supraventricular arrhythmias. In this document, SVT isused to describe re-entrant arrhythmias involving the atrioventricular (AV) junction (atrioventricular nodal reciprocating tachycardia [AVNRT]), atrium [atrial tachycardia (AT)],or AV-reciprocating rhythms [atrioventricular reciprocatingtachycardia (AVRT)]). For our purposes, the term “supraventricular arrhythmia” refers to all types of supraventriculararrhythmias, excluding AF, as opposed to SVT, whichincludes AVNRT, AVRT, and AT.These guidelines first present a review of the definition,public health, epidemiology, general mechanisms, and clinical characteristics of SVT. The management of each specifictachycardia is then presented, including a review of the existing literature relating to drug versus catheter ablative therapy. The treatment algorithms include pharmacologic andnonpharmacologic antiarrhythmic approaches thought to bemost appropriate for each particular condition. Overall, thisis a consensus document that includes evidence and expertopinions from several countries. The pharmacologic andACC - www.acc.orgAHA - www.americanheart.orgESC - www.escardio.orgnonpharmacologic antiarrhythmic approaches discussedmay, therefore, include some drugs and devices that do nothave the approval of governmental regulatory agencies.Because antiarrhythmic drug dosages and dr
The North American Society for Pacing and Electro-physiology-Heart Rhythm Society assigned one organiza-tional reviewer to the guideline. In addition, 37 external con-tent reviewers participated in the review representing the ACC/AHA Task Force on Practice Guidelines, the ESC
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