Clinical Review & Education
JAMA Cardiology Clinical Guidelines Synopsis
Acute Treatment of Patients With Supraventricular Tachycardia
Sana M. Al-Khatib, MD, MHS; Richard L. Page, MD
GUIDELINE TITLE: 2015 American College of Cardiology/
American Heart Association/Heart Rhythm Society Guideline
for the Management of Adult Patients With Supraventricular
Tachycardia
DEVELOPERS: American College of Cardiology, American Heart
Association, and Heart Rhythm Society
RELEASE DATES: September 23, 2015 (online); April 5, 2016
(print)
PRIOR VERSION: October 14, 2003
FUNDING SOURCES: American College of Cardiology, American
Heart Association, and Heart Rhythm Society
TARGET POPULATION: Adults with supraventricular
tachycardia (SVT)
MAJOR RECOMMENDATIONS: This guideline offers
recommendations for the management of SVT. Atrial
fibrillation was not covered. This synopsis summarizes
recommendations on the acute management of SVT.
• Vagal maneuvers and adenosine are recommended
(moderate-quality evidence) for the termination of regular
SVT of uncertain type, atrioventricular nodal reentrant
tachycardia, and atrioventricular reentrant tachycardia.
• Synchronized cardioversion is recommended (moderate-
quality evidence) for the termination of any
hemodynamically unstable SVT.
Summary of the Clinical Problem
Supraventricular tachycardia (SVT) is relatively common in adult
Americans, with 89 000 newly diagnosed cases each year and a
prevalence of 570 000 persons.1 Supraventricular tachycardia ac-
counts for approximately 50 000 emergency department visits each
year.1 The manifestations of SVT vary widely, from total lack of symp-
toms to debilitating symptoms with substantial effects on patient
functional status and quality of life.
Clinicians should be able to recognize SVT when they detect
regular narrow complex tachycardia and should know how to treat
patients with SVT. Key steps in the assessment and treatment of pa-
tients with SVT are determining whether a patient is hemodynami-
cally stable and deciding whether any symptoms reported by the pa-
tient are indeed owing to the SVT. Another important step is to try
to establish the mechanism of the tachycardia because this will help
inform the best treatment course. Finally, it is critically important to
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• In the absence of hemodynamic compromise, SVT should be
treated (moderate-quality evidence) with synchronized
cardioversion when pharmacologic therapy is ineffective or
contraindicated.
• Intravenous diltiazem, verapamil, or metoprolol is
recommended for control of heat rate in patients with
hemodynamically stable atrial flutter (moderate-quality
evidence) and for the treatment of hemodynamically stable
focal atrial tachycardia (low-quality evidence).
• Intravenous diltiazem, verapamil, or metoprolol can be useful
in terminating hemodynamically stable regular SVT of
uncertain type (moderate-quality evidence for diltiazem and
verapamil and low-quality evidence for β-blockers), multifocal
atrial tachycardia (low-quality evidence for metoprolol and
verapamil and none for diltiazem), atrioventricular nodal
reentrant tachycardia (moderate-quality evidence for all), and
orthodromic atrioventricular reentrant tachycardia in the
absence of pre-excitation on the resting electrocardiogram
(moderate-quality evidence for diltiazem and verapamil and
low-quality evidence for β-blockers).
• Anticoagulation is recommended (moderate-quality
evidence) in patients with atrial flutter to mirror
recommended anticoagulation for patients with atrial
fibrillation.
• Treatment of pre-excited atrial fibrillation with intravenous
digoxin, intravenous amiodarone, intravenous or oral β-
blockers, diltiazem, and verapamil is potentially harmful
(low-quality evidence). Instead, intravenous ibutilide or
procainamide is recommended (low-quality evidence) for
the treatment of hemodynamically stable pre-excited atrial
fibrillation.
review the patient’s medical history to discover any potential con-
traindications to therapies that could be administered in these set-
tings (Figure).2,3
Characteristics of the Guideline Source
This guideline was developed by the American College of Cardiology,
the American Heart Association, and the Heart Rhythm Society.2 The
guideline writing committee included 17 members: 14 adult electro-
physiologists,1pediatricelectrophysiologist,1generalcardiologist,and
1 patient/consumer representative. The development of recommen-
dations was based on all available evidence, with literature searches
focusing on randomized clinical trials, registries, nonrandomized com-
parative and descriptive studies, and systematic reviews.
The rigor of each recommendation in the guideline document
was designated by a class of recommendation and a level of evi-
dence (LOE).4 The class of recommendation is a measure of the
(Reprinted) JAMA Cardiology July 2016 Volume 1, Number 4 483
 Clinical Review & Education JAMA Cardiology Clinical Guidelines Synopsis

version, β-blockers, calcium-channel blockers, digoxin, antiarrhyth-

Figure. Treatment of Regular Supraventricular Tachycardia
of Uncertain Type mic medications (such as ibutilide and amiodarone), and rapid atrial
pacing. The published literature was reviewed extensively through
Regular supraventricular September 2014. Studies were reviewed if they involved human
tachycardia participants, were published in English, and indexed in Medline
(through PubMed), Embase, the Cochrane Library, or the Agency
Vagal maneuvers and/or for Healthcare Research and Quality. For each clinical question, all
intravenous adenosine
(class I) studies generated by the literature search were systematically
reviewed. Of the nearly 450 studies reviewed, only 4 were ran-
If ineffective or not feasible domized clinical trials, and the rest were primarily observational
studies.3
Of the 36 recommendations involving the management of SVT,
Hemodynamically 25 were class I recommendations, 10 were class IIa recommenda-
stable tions, 0 were class IIb recommendations, and 1 was a class III rec-
ommendation. Of the 25 class I recommendations, 1 had an LOE A,
Yes No
7 had an LOE B-R, 10 had an LOE B-NR, 7 had an LOE C, and none
had an LOE E.
Intravenous ß-blockers, Synchronized cardioversion
intravenous diltiazem, or (class I)
intravenous verapamil
(class IIa) Benefits and Harms
The potential benefits and harms of each intervention were care-
If ineffective or not feasible fully considered. Interventions used for the termination of SVT are
generally safe as long as no contraindications exist. For example,
Synchronized cardioversion β-blockers and calcium-channel blockers should not be given in the
(class I) presence of hypotension. The 1 recommendation involving harm was
related to giving digoxin, amiodarone, β-blockers, or calcium-
Colors correspond to the class of recommendation. Adapted with permission channel blockers for pre-excited atrial fibrillation.
of the American College of Cardiology Foundation, the American Heart
Association Inc, and the Heart Rhythm Society.3
Discussion
In developing this guideline document, high-quality evidence was
strength the guideline writing committee assigns to the recommen-
unavailable for many of the recommendations. Reasons for the lack
dation when examining the expected magnitude and certainty of
of high-quality evidence are several and include the longstanding use
benefit in proportion to risk. The class of recommendation can be
of the current interventions and the favorable safety profile of most
class I, indicating that the benefit of the intervention far exceeds the
interventions that make it almost impossible to study these inter-
risk; class IIa, indicating that the benefit of the intervention moder-
ventions in contemporary randomized clinical trials. However, the
ately exceeds the risk; class IIb, indicating that the benefit may not
guideline is based on the strongest available evidence and is help-
exceed the risk; and class III, indicating that the benefit is equiva-
ful in guiding treatment options for the termination of SVT.
lent to or is exceeded by the risk. The LOE can be A (evidence from
high-quality randomized clinical trials), B-R (evidence from moderate-
quality randomized clinical trials), B-NR (evidence from well- Areas in Need of Future Study or Ongoing Research
designed nonrandomized studies), C (evidence from randomized or New medications for the termination of SVT are needed, and stud-
nonrandomized studies with limitations), or E (expert opinion).4 ies that can elucidate the best drug for each individual patient are
The chair and most guideline writing committee members had necessary. In that regard, it is particularly important to generate
to have no relevant relations with industry. evidence on the best treatment approaches to older patients and
pregnant women. The best treatments for less common types of
Evidence Base SVT, such as junctional tachycardia, should be defined. Finally,
For the termination of SVT, the guideline addressed the following more studies should examine patient-centered outcomes and cost-
interventions: vagal maneuvers, adenosine, synchronized cardio- effectiveness data.

ARTICLE INFORMATION
Author Affiliations: Duke Clinical Research
Institute, Division of Cardiology, Duke University
Hospital, Durham, North Carolina (Al-Khatib);
Department of Medicine, School of Medicine and
Public Health, University of Wisconsin, Madison
(Page).
Corresponding Author: Sana M. Al-Khatib, MD,
MHS, Duke Clinical Research Institute, Division of
Cardiology, Duke University Hospital, 2400 Pratt
St, Durham, NC 27705 (alkha001@mc.duke.edu).
Published Online: June 8, 2016.
doi:10.1001/jamacardio.2016.1483.
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and
none were reported.
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