European Heart Rhythm Association (EHRA) Rhythm Society .

Page 3 of 47EHRA consensus document on the management of SVTTable 1 Scientific rationale of recommendationsScientific evidence that a treatment orprocedure is beneficial and effective.Requires at least one randomizedtrial, or is supported by strongobservational evidence and authors’consensus.General agreement and/or scientificevidence favour the usefulness/efficacy of a treatment or procedure.May be supported by randomizedtrials that are, however, based onsmall number of patients to allow agreen heart recommendation.Scientific evidence or generalagreement not to use or recommenda treatment or procedure.Recommended/indicatedTable 2 Conventional classification of supraventriculartachycardiasAtrial tachycardiasSinus tachycardiaPhysiological sinus tachycardiaInappropriate sinus tachycardiaMay be used orrecommendedSinus node reentrant tachycardiaAtrial tachycardiaFocal atrial tachycardiaMultifocal atrial tachycardiaShould NOT be usedor recommendedThis categorization for our consensus document should not be considered as beingdirectly similar to that used for official society guideline recommendations whichapply a classification (I –III) and level of evidence (A, B, and C) to recommendations.Macro-reentrant tachycardiaCavotricuspid isthmus-dependent, counter-clockwise orclockwise (typical atrial flutter)Non cavotricuspid isthmus– dependent, mitralisthmus-dependent, and other atypical left or right atrial fluttersAtrioventricular junctional tachycardiasAtrioventricular nodal reentrant tachycardiaTypicalAtypicalNon-reentrant junctional tachycardiaNon-paroxysmal junctional tachycardiaFocal junctional tachycardiarhythm (Table 2). The term narrow-QRS tachycardia indicates thosewith a QRS duration 120 ms. A wide-QRS tachycardia refers toone with a QRS duration .120 ms (Table 3). In clinical practice,SVT may present as narrow- or wide-QRS tachycardias, and mostof them usually, although not invariably, manifest as regular rhythms.This position paper does not cover atrial fibrillation, which is thesubject of a separate clinical guideline, as well as various consensusdocuments.Relationships with industry and otherconflictsEpidemiologyIt is EHRA/ESC policy to sponsor position papers and guidelineswithout commercial support, and all members volunteered theirtime. Thus, all members of the writing group as well as reviewershave disclosed any potential conflict of interest in detail, at theend of this document.Definitions and classificationThe term supraventricular literally indicates tachycardias (atrial and/or ventricular rates .100 bpm at rest), the mechanism of which involves tissue from the His bundle or above.1,2 Traditionally, SVT hasbeen used to describe all kinds of tachycardias apart from ventricular tachycardias and atrial fibrillation (AF) and has, therefore, included tachycardias such as atrioventricular reentry due toaccessory connections that is not, in essence, a supraventricularOther non-reentrant variantsAtrioventricular tachycardiasAtrioventricular reentrant tachycardiaOrthodromicAntidromic (with retrograde conduction through the AV node or,rarely, through another pathway)Supraventricular arrhythmias are relatively common, but rarely lifethreatening. However, precise description of the epidemiology ofSVT is difficult as there is often poor distinction between AF, atrialflutter (AFL) and other supraventricular arrhythmias. In contrast tothe extensive epidemiology on AF, specific focus on SVT populationepidemiology is sparse.In a 3.5% sample of medical records in the Marshfield (Wisconsin)Epidemiologic Study Area (MESA) the prevalence of paroxysmalSVT was 2.25/1000 persons, and the incidence was 35/100 000person-years.4 Based on these old data, it was estimated that thereare 89 000 new cases per year, and 570 000 patients with paroxysmal SVT in the USA.The precipitants of SVT can be related to age, sex, and associatedcomorbidities. Thus, in the general population appear to be twoDownloaded from by guest on November 20, 2016evidence that it is beneficial and effective. A yellow heart indicatesthat general agreement and/or scientific evidence favour the usefulness/efficacy of a treatment or procedure. May be supported by randomized trials that are, however, based on small number of patientsto allow a green heart recommendation. Treatment strategies forwhich there has been scientific evidence that they are potentiallyharmful and should not be used are indicated by a red heart. European Heart Rhythm Association grading of consensus statementsdoes not have separate definitions of Level of Evidence. The categorization used should not be considered as being directly similarto that used for official society guideline recommendations whichapply a classification (I – III) and level of evidence (A, B, and C) torecommendations.Overall, this is a consensus document that includes evidence andexpert opinions from several countries. The pharmacologic andnon-pharmacologic antiarrhythmic approaches discussed may,therefore, include drugs that do not have the approval of governmental regulatory agencies in all countries.

Page 4 of 47Table 3 Differential diagnosis of narrow and wide QRStachycardiasNarrow QRS ( 120 ms) tachycardiasRegularPhysiological sinus tachycardiaInappropriate sinus tachycardiaSinus nodal reentrant tachycardiaFocal atrial tachycardiaAtrial flutterAtrial fibrillation with very fast ventricular responseAtrioventricular nodal reentrant tachycardiaNon-paroxysmal or focal junctional tachycardiaOrthodromic atrioventricular reentrant tachycardiaIdiopathic ventricular tachycardia (especially high septal VT)IrregularAtrial fibrillationAtrial focal tachycardia or atrial flutter with varying AV blockMultifocal atrial tachycardiaWide QRS (.120 ms) tachycardiasRegularAntidromic atrioventricular reentrant tachycardiaAny regular atrial or junctional reentrant tachycardias with:Ventricular tachycardia/flutterIrregularAtrial fibrillation or atrial tachycardia with varying blockconducted with aberrationAntidromic atrioventricular reentrant tachycardia with a variableVA conductionpattern on ECG tracings in the general population is 0.1% to0.3%. However, not all patients with manifest ventricular preexcitation develop paroxysmal SVT.6,8 In female, middle-aged orolder persons, atrioventricular nodal reentrant tachycardia(AVNRT) is more common. In younger subjects (e.g. adolescents),the prevalence may be more balanced between atrioventricular reentrant tachycardia (AVRT) and AVNRT. Porter et al. described1754 patients undergoing catheter ablation, where AVNRT wasthe most common (56%) aetiology, followed by AVRT 27%, and atrial tachycardia (AT) 17%.9 The proportion of AVRT decreased withage, whereas the proportion of AVNRT and AT increased. Most patients with AVRT were male (55%), in contrast to patients withAVNRT and AT who were predominantly female (70% and 62%, respectively). Recently, in the first Latin American registry on catheterablation including 15 099 procedures from 120 centres in 13 participating countries, AVRT was the group of arrhythmias most frequently ablated (31%), followed by AVNRT (29%), typical AFL(14%), and AF (11%).10Limited population data on other supraventricular arrhythmias(apart from AF) are available. For AFL, one report from MESA of181 new cases of AFL estimated an overall incidence of 88/100000 person-years.11 Incidence rates ranged from 5/100 000 in those,50 years old to 587/100 000 in subjects older than 80 years. Atrialflutter was 2.5-fold more common in men, 3.5-fold more commonin subjects with heart failure, and 1.9-fold more common in subjectswith chronic obstructive pulmonary disease. Only 3 subjects (1.7%)were labelled as having ‘lone AFL’. In MESA, AFL had an incidence of0.09% and 58% of the patients also had AF. These data translate to200 000 new cases of AFL in the USA annually, the arrhythmia beingmore common in men, the elderly and individuals with pre-existingheart failure or chronic obstructive lung disease.Pre-excited AFPolymorphic VTTorsade de pointesVentricular fibrillationdistinct subsets of patients with paroxysmal SVT: those with othercardiovascular disease and those with lone paroxysmal SVT. InMESA, other cardiovascular disease was present in 90% of males,and 48% of females. Overall, females had 2-fold greater relative risk(RR) of paroxysmal SVT compared with males. Compared with patients with other cardiovascular disease, those with lone paroxysmalSVT were younger (mean 37 vs. 69 years), had a faster paroxysmalSVT heart rate (mean 186 vs. 155 beats/min) and were more likelyto have their condition first documented in the emergency room(69% vs. 30%). The onset of symptoms occurred during the childbearing years in 58% of females with lone paroxysmal SVT, vs. 9% of females with other cardiovascular disease. Older individuals (age.65 years) had .5-fold risk of developing paroxysmal SVT compared to younger subjects.4 Data from specialized centres reportingon paroxysmal SVT patients referred for electrophysiology procedures, indicate that patients tend to be younger, have similar age distribution, and lower prevalence of cardiovascular comorbidities.5 – 7The prevalence of SVT mediated by an accessory pathway decreases with age. For example, manifest pre-excitation or WPWClinical presentationThe clinical presentation of SVT usually reflects several factors suchas heart rate which can be quite variable depending on age, bloodpressure during the arrhythmia and resultant organ perfusion, associated comorbidities, and the individual patient symptom threshold(Table 4). Some patients with paroxysmal arrhythmias may beasymptomatic (or minimally symptomatic) at time of evaluation.Other patients can present with a variety of symptoms, even, rarely,Table 4 Most common symptoms during sustainedSVTCommonUncommonRareChest discomfort orpressureDyspnoeaChest theadedness,dizziness, orpresyncopePalpitationsNauseaSudden death with WPWsyndrome.PolyuriaSyncopeDownloaded from by guest on November 20, 2016aberration/bundle branch blockpre-excitation/bystander accessory pathwayD.G. Katritsis et al.

EHRA consensus document on the management of SVTDifferential diagnosis oftachycardiasNarrow QRS ( 120 ms) tachycardiasNarrow QRS complexes are due to rapid activation of the ventriclesvia the His-Purkinje system, which suggests that the origin of the arrhythmia is above or within the His bundle.

Force was convened by the European Heart Rhythm Association (EHRA) with representation from the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulacio n Cardiaca y Electrofisiologia (SO-LAECE), with the remit to comprehensively review the published