The AHA Guidelines and Scientific Statements Handbook

Chapter 16 Supraventricular Arrhythmias

retrograde conduction occurs over the fast pathway
(slow-fast AV node re-entry). Less commonly (5–
10%) the tachycardia circuit is reversed resulting in
a long R-P tachycardia (i.e., fast-slow AVNRT or
atypical AVNRT), with negative P waves in lead III
and aVF inscribed prior to the QRS. In slow–slow
AVNRT, the retrograde atrial activation fi rst occurs
over the slow pathway region once the RP interval
is greater than 70 ms.

Tr e a t m e n t

The treatment of AVNRT is predominantly

symptom-driven (Table 16.3). The choice between

drugs (AV-nodal blocking agents) vs. catheter abla-

tion is often governed by patient preference and

clinical judgment. The drug effi cacy is approxi-

mately 30–50% [9–12].

Single-dose therapy (“pill-in-the-pocket”) may be

considered for patients with infrequent, well-tolerated

Table 16.3 Recommendations for long-term treatment of patients with recurrent AVNRT

Clinical presentation Recommendation Class Level of evidence

Poorly tolerated AVNRT with hemodynamic
intolerance

Catheter ablation I B

Verapamil, diltiazem, beta-blocker, sotalol, amiodarone IIa C

Flecainide*, propafenone* IIa C

Recurrent symptomatic AVNRT Catheter ablation I B
Verapamil I B
Diltiazem, beta-blocker I C
Digoxin† IIb C

Recurrent AVNRT unresponsive to beta-
blockade or calcium channel blocker and
patient not desiring RF ablation

Flecainide,* propafenone,* sotalol IIa B

Amiodarone IIb C

AVNRT with infrequent or single episode in
patients who desire complete control of
arrhythmia

Catheter ablation I B

Documented PSVT with only dual AV nodal
pathways or single echo beats demonstrated
during electrophysiologic study and no other
identifi ed cause of arrhythmia

Verapamil, diltiazem, beta-blockers, fl ecanide†,

propafenone*

IC

Catheter ablation‡ I B

Infrequent, well-tolerated AVNRT No therapy I C
Vagal maneuvers I B
“Pill-in-the-pocket” I B
Verapamil, diltiazem, beta-blockers I B
Catheter ablation I B

The order in which treatment recommendations appear in this table within each class of recommendation does not necessarily refl ect a preferred sequence of
administration.

• Relatively contraindicated in patients with coronary artery disease, left ventricular dysfunction, or other signifi cant heart disease.
  † Digoxin is often ineffective because its pharmacologic effects can be overridden by enhanced sympathetic tone.
  ‡ Decision depends on symptoms.
  AV, atrioventricular; AVNRT, atrioventricular nodal reciprocating tachycardia; PSVT, paroxysmal supraventricular tachycardia; RF, radiofrequency.