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} =,