ACC/AHA Task Force on Practice Guidelines and the ESC Committee for Practice Guidelines VMs aes suepeinsecisyutcudieny = |Carina Blomstré6m-Lundaqvist (Sweden)®:°, Co-Chair Melvin M Scheinman (usa)?, Co-Chair Etienne M Aliot (France)#¢ Karl H Kuck (Germany)®* Joseph S Alpert (usay2¢ Bruce B Lerman (usa)? Hugh Calkins (Usa)?® D Douglas Miller (Usa)? A John Camm (uk)2:2¢ Charlie Willard Shaeffer Jr (USA) W Barton Campbell usa)?” William G Stevenson (usa)? David E Haines (usa)? Gordon F Tomaselli (usa)#:° American College of Cardiology; ° American Heart Association; ° European Society of Cardiology VMs aes suepeinsecisyutcudieny = |Europoan Heart Journal (2003) 24, 1857-1897 ELSEVIER ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias* — executive summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias) Developed in collaboration with NASPE—Heart Rhythm Society Committee Members, Carina Blomstrém-Lundqvist, (Co-chair)*', Melvin M, Scheinman, (Co-chair)*, Etienne M, Aliot***, Joseph S, Alpert®**, Hugh Calkins*®, A, John Camm***s, W, Barton Campbell*”, David E. Haines*, Karl H. Kuck®**, Bruce B. Lerman*, D. Douglas Miller*, Charlie Willard Shaeffer Jr°, William G. Stevenson”, Gordon F, Tomaselli*” Te Te 5 55 hfe fee OU} Sissy suelst7 9 Sc, udielogyLevels of recommendation Strength of BY-ilali Cola) recommendation (elon Evidence and/or general agreement that a given treatment Clg ieorecte Oe MMS U-UteRe ie) Class II Conflicting evidence and/or divergence of opinions about the usefulness/efficacy of a treatment or procedure Tet Merce enc rnaieane wena Mallet) IIb Usefulness/efficacy is less well established by evidence/opinion Class II! Evidence or general agreement that the treatment/procedure is not useful/effective and in some ee Mtg na LLL) Sere elS iiss iff eo Loh =Levels of evidence a a © Hei fefiiS5 if er des Sipe isin Seely of Calielugy | |¢ Group of common rhythm disturbances including rhythms emanating from: — Sinus node — Atrial tissue (atrial flutter) — Junctional/reciprocating or accessory pathway-mediated tachycardia ¢ Most common treatment strategies: — Antiarrhythmic drug therapy — Catheter ablation VMs aes suepeinsecisyutcudieny = |Initial evaluation of patients with suspected tachycardia Cinical history of palpitations 1laad EC hen) spect AVERT requ papas | ES 4° = atrial fibrilation; AV Sara cael ses EM ult Le reciprocating tachycardia; MAT = multifocal atrial tachycardia Rafer to arrhythmia speciDifferential diagnosis for narrow QRS tachycardia arom ORS racryconso | (ORS duration tess than 120 ms} ee y Regular tachycardia {RP shorter than PR) RP shorter than 70 rm ere Cen iiiECG pattern of typical AVNRT Serie (iiss Tiel ss eros SessaResponses of narrow complex tachycardias to adenosine Gradual slowing then reaccelration of race pa tachycardia * Focal AT cera junctional rec caria mech = Avial fucter “ATDifferential diagnosis for wide QRS-complex tachycardia (> 120 ms) Regular Vagal manoeuvres ‘or adenosine Yes or unknown y Precordial leads Typical + Concordant* = No R/S pattern = Onset of R to nadir longer than 100 ms RBEB SVT or LBBB Regular or irregular? Is ORS identical to that during SR? If yes, consider = SVT and BBB = Antidromic AVRT t Previous myocardial Infarction or structural heart disease? Ifyes, VT is likely. REBB pattern = gR, Rs or Rr! i Sirona parse axe range from +90 degrees to -90 degrees Atrial fibrillation Atrial flutter/AT with variable conduction and a) BBB or b) anterograde conduction via AP a ¥ ¥ V rate faster than Arate | Arate faster than V rate’ sH | LBBB pattern | | sitin & longer than 30 ms VT! | oR to nadir ofS inv, greater than 60 ms = QR orgs in Vz1 WAN f, Mpa NWyyhywyyn Vuy yy LoL oo, Sinn avr PORN MRNA ADS aw FOEAIA AAA A 4 NN TTY Late llee EM NC SVs (iiss Tiel is eos)IV procainamide FIV flecainide Acute management of haemodynamically stable and regular tachycardia Haemodynamically stable regular tachycardia y Y Narrow ORS Wide OR! SVT+BB8 Vagal manoeuvers Pre-excited IV adenosine T svt IV verapamil/diltiazem IV beta-blocker y per tachycardia with AV block ¥ plus AV.nodal-blocking agents ‘oF overdrive pacing/DC cardioversion, and/or rate control y Y * Definite SVT VT of unknown mechanism ise narrow ORS) Y IV procainamide IV sotalol WV lidocaine [lV amiodarone in patients with poor LV function) y ae) Pe Pee ere Menem erates] escent c) caution in patients Cee NCR eee) pate ee Ce) any Seal ae excitation fee MER Peon ae gent Tees nora Nemec eau en as Suet Can eaten a ne eect ce det Cena teeta ec STE Mae aco M Ae Eat mene ceceRecommendation? Grading Recommendation? Grading Narrow QRS-complex tachycardia (SVT) Vagal manoeuvres me} Adenosine IA Arlen el MP4) vA Beta-blockers ie} Amiodarone ilmes oor Tene! Wide QRS-complex tachycardia = SVT + BBB: As for narrow QRS-complex = Pre-excited SVT/AF Flecainide® =) 1LoTFi i folie IB Procainamide® IB DC cardioversion ie; SE ec nC Au eee iad ee Cu aaa tee Ms oe fibrillation; BBB = bundle-branch block; DC = direct current, LV = left ventricular, QRS = vertricular activation on ECG, Sale sc eae ee SHS 5 [felis ordi} =Recommendation? Grading Recommendation? Grading Wide QRS-complex tachycardia of unknown origin Procainamide® i) Sotalol ne} Amiodarone n=} DC cardioversion i) Liodocaine eee Adenosine® IIb C Beta-blockers? Ic Arlee IB Wide QRS-complex tachycardia of unknown origin in patients with poor LV function Amiodarone 1B DC cardioversion, is) lidocaine + Alllisted drugs are administered intravenously, * Should notbe taken by patierts with reduced LV function.» Adenosine should be used with caution in patients with severe coronary artery disease eee etees see maar ona ac tu ected eae ss cuca ee ener ek aan) feoteeie ee etree sd elena Nis is -T firstline therapy for those with catecholamine-sensttive Sea e eee Tene Menge Uiucen centre nee Sr cnet geet a SPA See (iiss Helse 3s ord F110Mic -an—ae Recommendation Grading Medical Beta-blockers nes Verapamil, diltiazem lac Interventional Catheter ablation — sinus node one} modification/elimination (as a last resort) Sree s5 tT fia ts Coody =Clinical presentation Recommendation Grading Poorly tolerated AVNRT with haemodynamic intolerance Recurrent symptomatic AVNRT Recurrent AVNRT, unresponsive to beta or calcium-channel blockers; patient not desiring RF ablation Catheter ablation Verapamil, diltiazem, beta blockers, sotalol, amiodarone Flecainide*, propafenone? Catheter ablation Verapamil Diltiazem, beta-blockers Digoxin’ Flecainide?, propafenone?: sotalol Amiodarone =) IEKe} llaCc IB IB Ic exe; llaB lee} * Relatively contraindicated for patients with coronary artery disease, left ventricular dysfunction, or other significant heart Cee ane Una licces Meet Pe mn au ele Sere Ne Se ec eye aN aS ee Cee eco eee eg SHS 5 [felis ordi} =Clinical presentation Recommendation Grading AVNRT with infrequent or single episode in Catheter ablation 1B patients who desire complete control of arrhythmia 1pJoe a -ial toes) VAIN ta Mela Nae 61-l NV ataTele(- YZ —ie-To%- Ln e741 1 (re pathways or single echo beats demonstrated _ blockers, flecainide®, during electrophysiological study and no other propafenone# identified cause of arrhythmia eral cier- lela 1B Infrequent, well-tolerated AVNRT Neh alee-leyg Ic Vagal manoeuvres ine) telltale ore. as} Verapamil, diltiazem, beta- a} ololol IE) Catheter ablation 1B * Relatively contraindicated for patients with coronary artery disease, left ventricular dysfunction, or other significant heart Cee mL eee a CEN aaa te SL ne ae Ice te PSVT = paroxysmal supraventricular tachycardia SHA Sef filS5 Tiel is ordi} =,ECG in focal junctional tachycardia tt ttt toto peilvalralalulabalaula lalallala wel WLLL LL Sinus rhythm L. ~ + TTT SII Tachycardia ne LA. L Lu i Jit. Be vi LILELI tty t (ECL Characteristic finding of isorhythmic atrioventricular dissociation Merete (iss fel fe Ores SesTachycardia Recommendation Grading Focal junctional Beta-blockers lla Cc tachycardia Flecainide lla Cc Propafenone? llac Sotalol? lac Amiodarone? lla C Or Nila le)r-i el Nonparoxysmal Reverse digitalis toxicity junctional tachycardia Correct hypokalemia Treat myocardial ischemia Beta-blockers, calcium-channel blockers Spree eee aot o SPA See (iiss Helse 3s ord F110Nia \vitglaalt-| Recommendation WPW syndrome (pre- Catheter ablation excitation and symptomatic Flecainide, propafenone arrhythmias), well tolerated Sotalol, amiodarone, beta-blockers Verapamil, diltiazem, digoxin WPW syndrome (with AF and Catheter ablation rapid-conduction or poorly tolerated AVRT) AVRT, poorly tolerated (no Ori leleicclmr=| 9) -lt(ea) a=} pre-excitation) Flecainide, propafenone Ewe} Sotalol, amiodarone Ewes Beta-blockers lee} Verapamil, diltiazem, digoxin ike} AF = atrial fibrillation; AVRT = atrioventricular reciprocating tachycardia; WPW = Wolff-Parkinson-White. SPA See (iiss Helse 3s ord F110Arrhythmia Recommendation Grading Single or infrequent AVRT episode(s) (no pre-excitation) Pre-excitation, asymptomatic None Vagal manoeuvres Pill-in-the-pocket — verapamil, diltiazem, beta-blockers leila) Sotalol, amiodarone Flecainide, propafenone Digoxin None Catheter ablation Ic IB IB eas} lb B exe} Ke} Ic SPA See (iiss Helse 3s ord F110Focal atrial tachycardia showing a long RP interval relationship AU bern pry Hl ALMA Hos MaMgaraayeid AU tinhClinical situation Recommendation ACUTE TREAMENT® A. Conversion Haemodynamically unstable DC cardioversion IB Haemodynamically stable Adenosine llac Beta-blockers llaC Verapamil, diltiazem llac Procainamide Ene} Flecainide/propafenone llaC Amiodarone, sotalol EMO} B. Rate regulation (in Beta-blockers Ic absence of digitalis) Verapamil, diltiazem Ic Digoxin lees Cisco Cit a eee enter icen acter econ ton imac: peace || (econ ere nn UCR CR ie aber eee ela Cee tet SHA Sef filS5 Tiel is ordi} =,Clinical situation Recommendation Grading PROPHYLACTIC THERAPY iStclol 1 e=101m-)/]08) 9 )Ce) tae AU Catheter ablation a) Beta-blockers, calcium-channel Ke} blockers Disopyramide® llac Flecainide®/propafenone® llac Sotalol, amiodarone llac Asymptomatic or symptomatic Catheter ablation 1B incessant ATS Nonsustained and No therapy Ic asymptomatic Catheter ablation like; ® Excluded are patients with MAT in whom beta blockers and sotalol are often contraindicated due to pulmonary disease. » Flecainide, propatenone, and dsopyramide snould not be used unless they are combined with an atnoventncular-nodal- yee acca eee nee CMe eee eee SHS 5 [felis ordi} =Cavotricuspid isthmus-dependent flutter COUNTERCLOCKWISE CLOCKWISE le) Starla aman =o) Note that the flutter waves are leads are predominantly negative positive in the inferior leads and Elace) MR dal=1e=r- CRU MOL Cclan Yaa predominantly negative double lead V1 are positive (arrow). ean (rC RA Serie (iiss Tiel ss eros SessaManagement of atrial flutter depending on haemodynamic stability ¥ Unstable v Stable | CHF shock, acute Ml ————— ~ | y “ Rate control Conversion pe rardieversion AV-nodal blockers > = DC cardioversion * Atrial pacing = Pharmacological conversion If therapy for prevention of recurrences warranted Md Antiarrhythmic drugs Catheter ablation | to electively revert atrial flutter to sinu fa sal ct zaClinical status Recommendation? Grading POORLY TOLERATED Conversion DC cardioversion Ic Rate control Beta-blockers llaC Verapamil/diltiazem llac Pyelicl oy lee} Amiodarone les SOc ere Mi ce Meta an ee a Reet eae cia cea ene na fallure. DC = direct current Meneses iis ZucpsunsucisyoreudiioyyClinical status Recommendation? STABLE FLUTTER (Oro) Z-1eJ10) 8) Atrial or transesophageal pacing DC cardioversion HT eyUiiT ie (a Flecainide? Propafenone? Sotalol Procainamide? Amiodarone Rate control Diltiazem/verapamil Beta-blockers Digitalis’ Amiodarone ® All drugs are administered intravenously. ® Dicitalis may be especially useful for rate control in patients with heart failure. Sane ei Rese tec una Cem ae Oh go) CPs CoCr er Ce eet aC La Seer en eR RM ue ager ees aoe a ta eencae SHS 5 [felis ordi} =Clinical status Recommendation Grading First episode and well-tolerated atrial Cardioversion alone IB aig Catheter ablation® llaB Recurrent and well-tolerated atrial flutter Catheter ablation? 1B ple) fe[-) lac Amiodarone, sotalol, flecainide?, IIb C quinidine>, propafenone?“, procainamide®<, disopyramide>< Poorly tolerated atrial flutter Catheter ablation® IB Atrial flutter appearing after use of class Catheter ablation® a=) Ic agents or amiodarone for AF Stop current drug and use another lla C Symptomatic non-CTl-dependent flutter © Catheter ablation® cus) after failed antiarrhythmic drug therapy = Catheter ablation of the AV junction end insertion of a pacemaker should be considered if catheter ablative cure Is not possible and the patient fails drug therapy.» These drugs should not be taken by patients with significant structural cardiac disease. Use of anticozaulants is fete eye ere hed cr k nO eee Cee ee RC CLC eau eee es ett) uniess they are combined with an AV-noda-olocking agent. AF = atrial fibrilation, AV = arioventncular, CTI = cavotncuspid isthmus SPA See (iiss Helse 3s ord F110Treatment strategy Recommendation Grading Acute conversion of PSVT Vagal manoeuvre Ic Adenosine Ic DC cardioversion le Metoprolol, propanolol llac Verapamil llbc Prophylactic therapy ip yfeloo day I[(@ Metoprolol? IB Propanolol? EWS) Sotalol?, flecainide® llac Quinidine, propafenone, verapamil IIb C beaceoleTar Wale eee} Catheter ablation IIb C Atenolol® tS} Amiodaraone Ke; Bacteremia tc Menu ecm ec cue ute aye eee eee et with flecainide end propafenone for certain tachycardias. » Atenololis categorized in clase C (drug classifcaton for use during pregnancy) by legal authorites in some European countries. DC = direct current; PSVT = paroxysmal supraventricular tachycardia SPA See (iiss Helse 3s ord F110Ore) ol] Cola Recommendation? Grading Par eke Me Uene te Tek elite ed Repaired ASD - Mustard or Senning repair of transposition of the great vessels - Unrepaired asymptomatic ASD not haemodynamically significant - Unrepaired haemodynamically significant ASD with atrial flutter? - PSVT and Ebstein's anomaly with haemodynamic indications for surgical repair Catheter ablation in experienced centre Catheter ablation in experienced centre Closure of ASD for treatment of the Ela | Closure of ASD and ablation of the alicia lea) Surgical ablation of accessory pathways at time of operative repair of the malformation at experienced CT) * Conversion and antarrhythmic drug therapy initial management as described for atrial flutter ASD = atrial septal defect; Seu eric ona a ceniceg Sere Te 5 iss iff ey} =