Treat SVT as per recent guidelines

1. Dr. Vijay Yadav
DM Resident 1st year
MCVTC, IOM
2019 ESC GUIDELINES FOR THE
MANAGEMENT OF PATIENTS WITH
SUPRAVENTRICULAR TACHYCARDIA

2. Introduction
• Atrial rates > 100 bpm at rest
• Origin: His bundle or above
• SVT may present as narrow QRS (<120msec) or wide
QRS (> 120msec) tachycardias
• Atrial fibrillation is not covered.

3. Classification
 Atrial tachycardias
 Sinus tachycardia
 Physiological ST
 Inappropriate ST
 Sinus nodal re-entrant
 Focal AT
 Multifocal AT
 Atrial flutter (MRAT)
 Cavotricuspid isthmus
dependent
 Non-cavotricuspid
isthmus dependent
 Atrial fibrillation
 AV Junctional
tachycardias
 Typical AVNRT
 Atypical AVNRT
 Atrioventricular re-
entrant tachycardia
(AVRT)
 Orthodromic AVRT
 Antidromic AVRT

4. YET ANOTHER WAY…
LONG RP TACHYCARDIA (RP>PR):
• Atypical AVNRT
• Atrial tachycardia
• Sinus node reentry
• Sinus tachycardia
• Permanent Junctional Reciprocating Tachycardia
SHORT RP TACHYCARDIA (RP<PR):
• Typical AVNRT
• Orthodromic AVRT

5. Narrow QRS tachycardias
Regular
• Physiological ST
• Inappropriate ST
• SNRT
• AFL with fixed AV
conduction
• AVNRT
• Focal AT
• JET
• Idiopathic VT (High septal
VT)
• Orthodromic AVRT
Irregular
• AF
• Focal AT or AFL with
varying AV block
• Multifocal atrial
tachycardia (MAT)

6. Wide QRS tachycardias
Regular
• SVT with aberration/BBB (pre-
existing or rate dependent
during tachycardia)
• AT or Junctional tachycardia
with pre-excitation
• SVT with QRS widening due to
dyselectrolytemia or
antiarrhythmics
• Antidromic AVRT
Irregular
• Focal AT or AFL or AF
with varying conduction
with aberrancy
• Antidromic AVRT with
varying AV block
• Pre-excited AF (WPW +
AF)

8. Intermittent AV
block
Focal AT, AFL, AF
Temporary
decrease in atrial
rate
Focal AT, ST, JET
Tachycardia
termination
AVNRT, AVRT
No effect AFL (MRAT)
Fascicular VT
Response to carotid
massage

9. PHYSIOLOGICAL SINUS TACHYCARDIA
Physiological Emotion, Exercise, Pain, Pregnancy
Pathological Anemia, Fever, Dehydration, Infection,
Cardiac MI, PE, CCF, Pericarditis, Shock
Endocrine Hyperthyroidism, Hypoglycemia, Pheochromocytoma,
Cushing’s disease, DM with ANS dysfunction
Drugs Adr, Norad, Dopa, Dobuta, Atropine, B2 agonist, B-blocker
withdrawl
Rx the underlying cause

10. Inappropriate Sinus Tachycardia
 Sinus rate >100 bpm that is out of
proportion with the level of
physical, emotional, pathological or
pharmacological stress.
 Young and Female
 Mechanism:
 Dysautonomia
 Neurohormonal dysregulation
 Intrinsic SA node hyperactivity
 Gain of function of HCN4 gene
mutation
 Anti-B receptor IgG
 Diagnosis:
 Holter: Average HR > 90 bpm with
HR > 100 bpm during waking hours
 Class I:
 Rx of reversible causes
 Class IIa: (B)
 Ivabradine alone or
 Ivabradine + B-blocker
 Class IIa: (C)
 B-blocker

11. Focal Atrial Tachycardia (10-15% of SVT’s)
Causes ECG findings
Digitalis toxicity P’ wave differs from sinus P wave, may
be inverted or upright
Alcohol Atrial rate: 100-250 bpm
COPD RP interval (> 70 msec) >> PR interval
MI AV conduction may be impaired
Surgical atriatomy scar
FAT origin ECG changes
LA (pulmonary veins, IAS,
mitral annulus)
Positive P’: V1
Negative P’: I or aVL
RA (crista terminalis) Positive/Biphasic P’: aVL
Negative/Biphasic P’: V1

12. Focal Atrial Tachycardia
 Class I:
 DC shock if unstable
 Class IIa:
 Adenosine (6-18mg)
 IV Verapamil/Diltiazem
 IV Esmolol/Metoprolol
 Class IIb:
 IV Ibutilide
 IV Flecainide or
Propafenone
 IV Amiodarone

13. Focal Atrial Tachycardia
 Class I:
 Catheter ablation
 Class IIa:
 B-blocker
 Verapamil/Diltiazem
 Propafenone/Flecaini
de
 Class IIb:
 Ivabradine + B-
Blocker
 Amiodarone

14. Multifocal Atrial Tachycardia
 Rapid irregular rhythm with at
least 3 distict P wave
morphologies
 Distinct isoelectric period
between P waves
 Atrial rate: 100 – 130 bpm
 PP, PR, and RR intervals are
irregular
 Mechanism: DAD
 Associated with:
 Pulmonary disease
 Pulmonary HTN
 CAD
 VHD
 Hypomagnesemia
 Theophylline therapy
 Healthy infants < 1 year
 Signature tachycardia of
Acute Therapy
Rx underlying cause I
IV B-blockers/Verapamil
or Diltiazem
IIa
Chronic Therapy
Oral verapamil/diltiazem IIa
Oral beta blocker IIa
AVN ablation if recurrent,
resistant and with LV
dysfunction
IIa
IV Magnesium even in
patients with normal
magnesium levels
Arrhythmia most resistant
to DC shock

15. Atrial Flutter
(MRAT- Macro-reentrant Atrial Tachycardia)
 Macro-re-entry in RA
 Anteriorly: Tricuspid annulus
 Posteriorly: Crista terminalis & Eustachian ridge
 Atrial rate: 250-350
 Ventricular rate: 75-175
 Typical AFL:
 Involves CTI
 Activation goes down in the RA free wall, through the CTI, and
ascends in the right septum
 Has a typical ECG pattern
 Amenable to ablation
 Atypical AFL
 Doesn’t involve CTI
 Has a variable ECG pattern
 Recurrences more common but still amenable to ablation

16. • Upper loop reentry
• RA free wall
• Septal atrial flutter
• Mitral annular flutter
• MAZE flutter
• Type 1/Counter-clockwise
• Clockwise
• Lower loop reentry
Typical AFL/MRAT Atypical AFL/MRAT
TYPE RE-ENTRY ECG (lead II,II,aVF) ECG (lead V1 & V6)
Typical/Counter-
clockwise/Type 1
CTI Saw-tooth flutter
wave
Negative flutter
waves in II,III,aVF
V1: Positive
V6: Negative
Typical Clockwise CTI “Inverse sawtooth
Positive in inferior
leads
V1: Negative
V6: Positive

17. Relationship between AF & AFL
• Both are associated with similar clinical settings
• Both can co-exist in the same patient
• AF may trigger atrial flutter
• AF is common after catheter ablation of typical flutter
• Typical flutter can occur in patients treated for AF with
amiodarone or class IC drugs

18. ACUTE THERAPY OF
AFL/MRAT
HEMODYNAMICALLY
UNSTABLE
Class I:
• Synchronized DC
cardioversion
HEMODYNAMICALLY
STABLE
Class I: (conversion to SR)
• IV Ibutilide
• IV/oral (in hospital) Dofetilide
• DC shock (≤ 100J Biphasic)
• High-rate atrial pacing in the
presence of PPM or ICD
Class IIa: (Rate control)
• IV beta-blocker
• IV verapamil/diltiazem
Class IIb:
• Invasive & Non-invasive high-atrial
pacing
• IV Amiodarone
Class III:
• Propafenone
• Flecainide
ANTICOAGULATION
Class I: AFL + AF
Class IIa: AFL - AF

19. CHRONIC THERAPY
OF AFL/MRAT
Class I:
• Catheter ablation: symptomatic, recurrent, both CTI and
non-CTI dependent flutter, or with LV dysfunction due to TCM.
Class IIa:
• If NO catheter ablation: IV beta-blockers or non-
dihydropyridine CCB if no HFrEF
• AVN ablation with pacing (“ablate & pace”)
Class IIb:
• Amiodarone if everything fails

20. Typical AVNRT
Atypical AVNRT
ATRIOVENTRICULAR JUNCTIONAL
TACHYCARDIA

21. AV Nodal Reentrant Tachycardia (AVNRT)
• Regular tachycardia that results from the formation of a
reentry circuit confined to the AV node and perinodal atrial
tissue
• 2/3rd of all SVT; Female > Male
Compact Zone, AV Node
Fast pathway
Coronary Sinus
Slow pathway

22. Initiation & Maintenance

23. TYPES OF AVNRT
1. Typical OR slow/fast AVNRT: M.C (85-90%)
2. Atypical OR fast/slow OR slow/slow AVNRT
ANTEGRADE RETROGRADE
ANTEGRADE RETROGRADE

24. Typical AVNRT
*Superimposition of P wave onto
the QRS complex. (retrograde
conduction is through fast
pathway)
*Short RP tachycardia
*Pseudo ‘r’ wave in V1 or pseudo ‘s’
wave in II, III, aVF
Atypical AVNRT
*Inverted P waves in II, III, aVF, and
V6 but positive in V1 and aVR
*Long RP tachycardia
HA interval
(Retrograde)
VA interval
(RP interval)
AH/HA ratio
Typical AVNRT ≤ 70 msec ≤ 60 msec > 1
Atypical AVNRT > 70 msec > 60 msec < 1

26. 0% 20% 40% 60% 80% 100% 120%
Palpitation
Dizziness
Dyspnoea
Chest pain
Fatigue
Syncope
Am J Cardiol. 1997;79(2):145.

27.  Class I:
 DC cardioversion if
unstable
 Vagal manoeuvres
 IV Adenosine (6-18mg)
 DC cardioversion if all
drugs fail
 Class IIa:
 IV Verapamil (5-10 mg
over 2 minutes)
 Diltiazem (0.25mg/kg
over 2 minutes)
 IV Beta-blocker
(esmolol or metoprolol)
AVNRT
ACUTE
THERAPY

28. Valsalva manoeuvre
* First line emergency treatment
* Blowing into a 10ml syringe with
sufficient force (40 mmHg) until
the plunger moves down
* Most effective in adults & in
AVRT>> AVNRT
* Supine repositioning & passive leg
raise after valsalva strain
(Modified version)
Carotid massage
*Outer & lateral boarder of
thyroid cartilage
*Press carotid artery for 30-
60 sec
*Do not press simultaneously
*Auscultate prior to
compression for bruit
*Vagal manoeuvres

30. ADENOSINE Endogenous purine analogue
6-18 mg
Rapid onset of action
T1/2: < 10 seconds
Repeat administration within 1
minute
Terminates 80% of AVNRT
Antidote: Theophylline
Half dose in:
• Cardiac transplant recipients
• Patients on Dipyridamole
• When given via CVP
Adverse effects:
• Flushing
• Transient dyspnoea (Pulm vagal C
fibers stimulation)
• Sinus bradycardia, arrest, AV block
• PVC, Polymorphic VT
• AF in 12% (↓Atrial RP)

31. Calcium channel blockers
• IV Verapamil 5-10 mg over 2
min
• IV diltiazem 0.25mg/kg over
2 min
• Terminates 64-98% of SVT
• Contraindications:
• EF < 40%
• Hemodynamic instability
• Suspected VT
• Pre-excited AF
• Intranasal Etripamil
• Short acting L type CCB
• Conversion rate: 65-95%
Beta-blockers
• IV esmolol
• 0.5mg/kg IVB or
• 0.05-0.3 mg/kg/min infusion
• IV metoprolol
• 2.5-15 mg
• Limited effectiveness
• Contraindicated in
decompensated HF

33. Repolarization abnormalities
 ST depression: 25-50%
 T wave inversion:
 Occurs after termination in 40% of patients
 Anterior or Inferior leads
 Immediately after termination or within first 6
hours
 Persist for hours to days

34. Chronic therapy for AVNRT
 Class I:
 Catheter ablation:
symptomatic,
recurrent AVNRT
 Class IIa: (If
ablation not
desired/feasible)
 Diltiazem/Verapamil
 Beta blocker

35. CATHETER ABLATION
“Low voltage, High frequency”, electrical current
Indications:
Refractory to medical management
Syncope, Angina, Severe dyspnoea
Pathway ablated: Slow pathway
M.C approach used: Posterior approach
M.C site of successful ablation: At the level of superior aspect of CS ostium
Marker for a successful ablation site: Development of junctional rhythm during RF
application
Success rate: > 95%
M.C complication: AV block (1%), Requires PPI in 1-3%
1st line of treatment for patients with AVNRT + Syncope

36. Cryoablation for AVNRT is
as effective as RFCA over
the short term. (98.4%
and 96.8%)
Higher recurrence rate at
the 6-month follow-up.
(9.4% vs 4.4%)
Equal risk of AV block.

37. Cryoablation for AVNRT using a focal 6-mm catheter was
safe and effective.
Low risk of recurrence over 6 months of follow-up.
No incidence of AV block requiring permanent pacing.

38. Orthodromic AVRT
Antidromic AVRT
ATRIO-VENTRICULAR RECIPROCATING
TACHYCARDIA (AVRT)
First described on 1930 by Dr. Wolff Parkinson & White

39. ORTHODROMIC (>90%)
• From Atrium to Ventricle:
AVN + HB
• From Ventricle to Atrium:
AP
ANTIDROMIC (3-8%)
• From Atrium to Ventricle:
AP
• From Ventricle to Atrium:
HB + AVN

41. Accessory pathways can be:
MANIFEST/WPW CONCEALED
 AP capable of antegrade
conduction
 Pre-excitation present
 Antidromic AVRT
 AP capable of only retrograde
conduction
 Pre-excitation absent
 Orthodromic AVRT
Left free wall >> Posteroseptal/Midseptal >> Right free wall >> Anteroseptal
AVRT (80%) >> AF (15-30%) >> AFL (5%)>> VT (rare)

42. AVNRT
• Absent P wave in 2/3rd and
retrograde P’ wave following QRS
in 1/3rd cases
• RR alterans & PR alterans
• Pseudo R’ in V1 & pseudo S wave
in II, III, aVF
• V1 (RP interval) – III (RP interval) >
20 msec
• Notched QRS in aVL
• Pseudo R’ in aVR
Orthodromic AVRT
• Retrograde P’ wave following
QRS in the ST segment or in
early T wave.
• QRS alterans
• ST depression (AVRT >>
AVNRT)
• QRS < 120 msec unless pre-
existing BBB or rate related
aberrant conduction.

43. Acute therapy of orthodromic
AVRT
 Class I:
 Synchronized DC
cardioversion
 Class I:
 Vagal manoeuvres
 Adenosine 6-18 mg
 DC cardioversion if
all drugs fail
 Class IIa:
 IV
verapamil/diltiazem
 IV
esmolol/metoprolol
Hemodynamically unstable Hemodynamically stable

44. Acute therapy of Antidromic
AVRT
 Class IIa:
 IV
Ibutilide/Procainamide
 IV
Propafenone/Flecainide
 Synchronized DC
cardioversion
 Class IIb:
 IV Amiodarone

45. Chronic therapy for AVRT
 Class I:
 Catheter ablation
 Class IIa:
 IV
verapamil/diltiazem
 IV beta blockers
 Class IIb:
 Propafenone
 Flecainide

46. Pre-excited AF (WPW + AF)
Hemodynamically unstable
• Class I:
• Synchronized DC cardioversion
Hemodynamically stable
• Class I:
• Synchronized DC cardioversion
if refractory to drugs
• Class IIa:
• IV Ibutilide/Procainamide
• Class IIb:
• Flecainide/Propafenone
• Class III:
• Amiodarone, B-blocker, CCB,
Digoxin

47. CATHETER ABLATION
Acute
success (%)
Recurrence
(%)
Complications
(%)
Mortality (%)
Focal AT 85 20 1.4 0.1
CTI AFL 95 10 2 0.3
AVNRT 97 2 0.3 0.01
AVRT 92 8 1.5 0.1

48. SVT during pregnancy
Class I: Catheter ablation with recurrent SVT who plan to become
pregnant
 Class I:
 DC cardioversion if
hemodynamically unstable
 Vagal manoeuvres
 Adenosine (SVT)
 Class IIa:
 IV beta blocker (except
atenolol) - SVT
 IV digoxin if B-Blocker fail
(AT)
 Class IIb:
 IV Ibutilide (AFL)
 Class I:
 Hold all antiarrhythmics in 1st
trimester if possible
 Class IIa:
 B1 selective B-blocker
(except atenolol) or Verapamil
without WPW
 Flecainide/Propafenone with
WPW and without structural
heart disease
 Fluoroless catheter ablation if
evrything fails
 Class III:
 Amiodarone
Acute therapy Chronic therapy

49. Take home message
 Amiodarone & Digoxin are no longer
mentioned for the acute management of
narrow complex tachycardia.
 Verapamil/Diltiazem & catheter ablation are no
longer recommended for IST. Rather
Ivabradine alone, B-blocker alone, or both
agents are now considered in symptomatic
patients. (IIa)

50. THANK YOU