2019 ESC Guidelines for the Management of Patients with Supraventricular Tachycardia

Authors, Journal, Affiliations, Type, DOI

• Chairpersons: Josep Brugada (Belgium), Demosthenes G. Katritsis (Greece)
• Task Force members: Elena Arbelo, Carina Blomström-Lundqvist, John Camm, Gian-Battista Chierchia, Richard Hauer, Siew Yen Ho, Pier-Damien Kirchhof, Karl-Heinz Kuck, Sabine Ernst, Laurent Haegeli, Gerhard Hindricks, Pedro Brugada, Francis E. Marchlinski, Isabelle Nault, Andrea Natale, Johann Bauersfeld, Alexis Garrigue, Alexandre Duytschaever, plus AEPC representation
• Journal: European Heart Journal; published online 31 August 2019; Volume 40, Issue 51, Pages 4768–4817
• Affiliation: European Society of Cardiology Task Force with AEPC endorsement
• Type: Clinical Practice Guideline (full text)
• DOI: https://doi.org/10.1093/eurheartj/ehz467

Overview

The 2019 ESC Guidelines for SVT replace the 2003 ESC guidelines and were developed concurrent with — but independently of — the 2015 ACC/AHA/HRS guideline. The document provides comprehensive, evidence-based recommendations for the classification, diagnosis, and management of all forms of SVT in adults, including IST, POTS, focal and multifocal AT, macro-re-entrant AT/atrial flutter, AVNRT, AVRT/WPW, tachycardiomyopathy, and special populations (ACHD, pregnancy, sports). Key advances over 2003 include upgraded class recommendations for catheter ablation as first-line therapy, formal incorporation of tachycardiomyopathy (TCM), updated asymptomatic pre-excitation management, and new evidence on the modified Valsalva manoeuvre. The guideline uses ESC Class of Recommendation/Level of Evidence scales and includes 22 formal recommendation tables, flow charts for acute and chronic management of each SVT subtype, and a comprehensive catheter ablation outcomes table (Table 11).

Keywords

Supraventricular tachycardia; atrioventricular nodal re-entrant tachycardia; atrioventricular re-entrant tachycardia; accessory pathway; Wolff-Parkinson-White syndrome; atrial tachycardia; atrial flutter; inappropriate sinus tachycardia; POTS; tachycardiomyopathy; catheter ablation; adenosine; vagal manoeuvres; pre-excited atrial fibrillation; pregnancy; congenital heart disease

Key Takeaways

Section 2: What is New in 2019?

• Key recommendation changes from 2003: verapamil/diltiazem for acute narrow QRS SVT downgraded I → IIa; beta-blockers for IST downgraded I → IIa; beta-blockers for focal AT chronic downgraded I → IIa; ibutilide for atrial flutter upgraded IIa → I; flecainide/propafenone for atrial flutter acute upgraded from recommended to Class III (harmful); atrial pacing for flutter conversion downgraded I → IIb
• New 2019 recommendations: Ivabradine (alone or with beta-blocker) IIa for IST; ibutilide IIb for focal AT acute; ibutilide/dofetilide I for flutter conversion; anticoagulation IIa for flutter without AF; ablation considered after first episode of symptomatic typical flutter (IIa); asymptomatic pre-excitation EPS and ablation for high-risk features now Class I; TCM section with Class I catheter ablation
• New 2019 concepts: Modified Valsalva manoeuvre; drug therapy updates for IST and focal AT; anticoagulation threshold for atrial flutter without AF; management of asymptomatic pre-excitation; TCM diagnosis and therapy

Section 6: Epidemiology

• SVT prevalence 2.25/1000 persons; incidence 35/100,000 person-years
• Women 2× higher risk than men; age ≥65 years >5× higher risk than younger individuals
• WPW pattern prevalence 0.15–0.25% general population; 0.55% first-degree relatives
• AVNRT most common ablated substrate after AF; women 70:30 ratio; AVRT 45:55 female:male
• Atrial flutter incidence 88/100,000 person-years (US); men incidence 2.5× women; increases exponentially with age

Section 9: Differential Diagnosis

• Wide QRS tachycardia: VT ~80%, SVT with BBB ~15%, pre-excited SVT ~5%
• AV dissociation = key diagnostic feature of VT; fusion/capture beats = diagnostic
• ECG criteria suggesting VT (Table 9): negative concordance (>90% specific), absent RS in precordials, RS >100 ms in any lead, QRS axis −90 to ±180°, R-wave peak time ≥50 ms in lead II (Pava criterion), aVR initial R or Q >40 ms or notch
• Short-RP SVTs (RP < half RR): typical AVNRT, orthodromic AVRT, focal AT with fast conduction; long-RP SVTs (RP > PR): atypical AVNRT, PJRT, focal AT, sinus tachycardia
• VA interval <70 ms (EPS) or <90 ms (surface ECG): strongly favours typical AVNRT

Section 10: Acute Management — Narrow QRS

Haemodynamically unstable: Synchronized DC cardioversion (I/B)
Haemodynamically stable:

• 12-lead ECG during tachycardia: I/C
• Vagal manoeuvres (supine + leg elevation): I/B — modified Valsalva (semi-recumbent then supine + passive leg raise after strain) converts 43% vs 17% conventional
• Adenosine 6–18 mg IV bolus if vagal manoeuvres fail: I/B
• Verapamil or diltiazem IV if vagal + adenosine fail: IIa/B
• Beta-blockers (esmolol/metoprolol IV) if vagal + adenosine fail: IIa/C
• DC cardioversion if drug therapy fails: I/B
• Adenosine dose range: mean 6 mg for termination; inject as rapid bolus with saline flush; repeat at 12 mg, then 18 mg; >90% success; caution in asthma (verapamil preferred in severe asthma); caution with pre-excitation on resting ECG

Section 10: Acute Management — Wide QRS

Haemodynamically unstable: Synchronized DC cardioversion (I/B)
Haemodynamically stable:

• Vagal manoeuvres: I/C
• Adenosine if no pre-excitation on resting ECG: IIa/C
• Procainamide IV if vagal + adenosine fail: IIa/B (PROCAMIO trial: fewer adverse events and higher termination rate than amiodarone within 40 min)
• Amiodarone IV if vagal + adenosine fail: IIb/B (downgraded from 2003 Class I)
• DC cardioversion if drug therapy fails: I/B
• Verapamil is not recommended (Class III/B) in wide QRS tachycardia of unknown aetiology

Section 11.1.1.2: Inappropriate Sinus Tachycardia

• Definition: sinus rate >100 bpm at rest or minimal activity, disproportionate to physiological stress; prognosis benign; no association with TCM
• Pathophysiology: multifactorial — dysautonomia, neurohormonal dysregulation, intrinsic sinus node hyperactivity; gain-of-function HCN4 mutation in familial IST; IgG anti-beta receptor antibodies in some cases
• Recommendations:
  • Evaluate and treat reversible causes: I/C
  • Ivabradine alone or with beta-blocker: IIa/B (upgraded from IIb in some prior versions; blocks If; CYP3A4 substrate — avoid with ketoconazole, verapamil, diltiazem, clarithromycin, grapefruit; avoid in pregnancy/breastfeeding)
  • Beta-blockers: IIa/C (often require doses causing intolerable fatigue)
  • Catheter ablation: NOT recommended for routine management — limited/disappointing evidence from small observational studies

Section 11.1.2: Focal Atrial Tachycardia

• Catheter ablation is treatment of choice for recurrent focal AT, especially incessant AT causing TCM: I/B; success rate 75–100%
• Acute: adenosine IIa/B; beta-blockers or CCBs IIa/C; ibutilide/flecainide/propafenone/amiodarone IIb/C
• Chronic: beta-blockers or CCBs or IC drugs (no structural/ischaemic disease) IIa/C; ivabradine + beta-blocker IIb/C; amiodarone IIb/C

Section 11.1.4: Macro-Re-entrant Atrial Arrhythmias / Atrial Flutter

• Acute — pharmacological cardioversion: Ibutilide IV or dofetilide IV/oral (in-hospital): I/B; low-energy (<100 J biphasic) electrical cardioversion: I/B; high-rate atrial pacing (with implanted device): I/B; IV beta-blockers or CCBs for rate control: IIa/B; invasive/non-invasive atrial pacing: IIb/B; IV amiodarone: IIb/C; flecainide/propafenone: III/B (contraindicated)
• Chronic: CTI ablation recommended for symptomatic recurrent CTI-dependent flutter: I/A; ablation considered after first symptomatic episode: IIa/B; beta-blockers or CCBs if ablation not feasible: IIa/C; amiodarone to maintain SR: IIb/C; AV nodal ablation + pacing if all else fails: IIa/C
• Anticoagulation: As for AF if concomitant AF (I/B); for flutter without AF: IIa/C (threshold not established; CHA₂DS₂-VASc not validated in isolated flutter)
• AFL complication rates (Table 11): acute success 95%; recurrence 10%; complications 2%; mortality 0.2%

Section 11.2.1: AVNRT

• Epidemiology: Bimodal onset — early in life OR fourth/fifth decade; 50% with minimal symptoms become asymptomatic within 1–3 years; may trigger AF that usually resolves after AVNRT ablation
• ECG: Short-RP (typical slow-fast); pseudo-R in V1, pseudo-S in inferior leads — specific 91–100% but sensitivity 58% and 14%; pseudo-R in aVR has higher sensitivity/specificity than pseudo-R in V1
• Acute (haemodynamically stable): Vagal manoeuvres I/B → adenosine I/B → verapamil/diltiazem IIa/B or beta-blockers IIa/C → DC cardioversion I/B; single-dose oral diltiazem 120 mg + propranolol 80 mg: up to 94% conversion (risk hypotension/syncope)
• Catheter ablation (chronic): I/B — 97% success; recurrence 1.3–4%; AV block <1% in modern series with inferior nodal extension targeting; cryoablation: lower AV block risk but higher recurrence — preferred in children; IST post-ablation usually transient; first-degree AVB = risk factor for late AV block, avoid extensive ablation
• Chronic pharmacotherapy if ablation not desired: Diltiazem/verapamil (without HFrEF) or beta-blockers: IIa/B; abstinence from therapy for minimally symptomatic, infrequent, short-lived episodes: IIa/C

Section 11.3: AVRT / Accessory Pathways / WPW

• Accessory pathway distribution: Left free wall 60%; septal 25%; right free wall 15%; multiple APs in ≤12% (≤50% in Ebstein's)
• Orthodromic AVRT: >90% of AVRTs; narrow QRS; RP up to half CL; functional BBB with ipsilateral AP prolongs CL
• Antidromic AVRT: 3–8% of WPW; wide QRS fully pre-excited; 30–60% have multiple APs
• Pre-excited AF: Found in 50% of WPW patients at some point; high-rate ventricular conduction → VF risk; cardiac arrest/VF risk 2.4 per 1000 person-years (95% CI 1.3–3.9)
• Acute orthodromic AVRT: Vagal manoeuvres I/B → adenosine I/B → verapamil/diltiazem IIa/B or beta-blockers IIa/C → DC cardioversion I/B
• Acute antidromic AVRT: Ibutilide/procainamide/flecainide/propafenone or DC cardioversion: IIa/B; amiodarone in refractory cases: IIb/B
• Pre-excited AF: DC cardioversion (unstable) I/B; ibutilide or procainamide IIa/B; flecainide or propafenone IIb/B; DC cardioversion if drugs fail I/B; IV amiodarone: III/B (not recommended — enhanced pathway conduction and VF reported); AV nodal agents (adenosine, verapamil, diltiazem, beta-blockers, digoxin): absolutely contraindicated
• Chronic: Catheter ablation I/B (>95% cure rate in experienced operators); beta-blockers or CCBs (no pre-excitation on resting ECG): IIa/B; flecainide/propafenone (no structural/ischaemic disease): IIb/B; digoxin, BB, diltiazem, verapamil, amiodarone: III/B in pre-excited AF
• Ablation outcomes (Table 11): AVRT acute success 92%; recurrence 8%; complications 1.5%; mortality 0.1%

Section 11.3.11: Asymptomatic Pre-excitation

• High-risk occupations/competitive athletes: EPS with isoprenaline mandatory: I/B
• High-risk EP features → ablation: I/B: SPERRI ≤250 ms, AP ERP ≤250 ms, multiple APs, inducible AP-mediated tachycardia
• EPS to risk-stratify general asymptomatic pre-excitation: IIa/B (consider in all)
• Non-invasive evaluation (exercise, drug testing, ambulatory monitoring): IIb/B
• If non-invasive suggests low risk → EPS still recommended if no absolute low-risk criteria: I/C
• Low-risk AP after EPS → clinical follow-up: IIa/C; ablation may be considered: IIb/C
• LV dysfunction from electrical dyssynchrony → ablation: IIa/C
• Ablation in experienced centres by patient preference: IIb/C
• Intermittent pre-excitation now recognized as imperfect risk marker — >1/5 with intermittent pre-excitation have AP ERP <250 ms

Section 14: SVT in Pregnancy

• SVT occurs 22–24/100,000 pregnancies; higher in third trimester/peri-partum
• Catheter ablation before pregnancy recommended for symptomatic women planning pregnancy: I/C
• All antiarrhythmic drugs avoided in first trimester if possible: I/C
• Acute: electrical cardioversion (unstable) I/C; vagal manoeuvres + adenosine I/C; beta-1 selective blocker (not atenolol) IIa/C
• Chronic: beta-1 selective blockers or verapamil (non-WPW): IIa/C; flecainide or propafenone (WPW or IC failure): IIa/C; amiodarone: III/C (contraindicated)
• Fluoroless catheter ablation (experienced centres): IIa/C
• Diltiazem potentially teratogenic — not generally recommended in pregnancy

Section 15: Tachycardiomyopathy (TCM)

• TCM = reversible cause of LV dysfunction due to persistent/frequent tachycardia; any arrhythmia can cause it; in patients <18 years, focal AT is commonest cause; PJRT in young
• Diagnosis: LV EF typically <30%; LVEDD <65 mm; LVESD <50 mm; CMR advisable; NT-proBNP ratio helps distinguish from irreversible DCM; serial monitoring essential
• Catheter ablation for TCM due to SVT: I/B; consider ablation whenever tachycardia responsible for TCM identified
• Beta-blockers (mortality-benefit proven in HFrEF): I/A if catheter ablation fails or not applicable
• AV nodal ablation + pacing (biventricular or His-bundle): I/C if tachycardia cannot be ablated or controlled by drugs
• Consider TCM in any reduced LVEF patient with HR >100 bpm: I/B
• 24-hour (or multi-day) ambulatory ECG monitoring: IIa/B

Section 16: SVT in Sports

• Catheter ablation recommended for all athletes with paroxysmal SVT (sympathetic stimulation → very fast rates → haemodynamic compromise even in structural normal hearts)
• WPW with competitive sports: ablation mandatory; allowed 1 month post-ablation if no recurrence
• Asymptomatic pre-excitation in athletes: invasive EPS/ablation per Section 11.3.11; abrupt disappearance on exercise testing suggests low risk but see caveats
• Beta-blockers/sodium channel blockers discouraged in athletes: reduced performance; prohibited by WADA in some sports

Limitations of the Document

• Most recommendations for SVT in pregnancy are Class C (consensus/case reports only; no RCTs)
• TCM incidence and natural history poorly characterized; no RCTs for TCM management
• Anticoagulation threshold for isolated atrial flutter without AF not established; CHA₂DS₂-VASc not validated in this population
• Atypical pre-excitation (Mahaim) and fascicular VT remain challenging to diagnose; ECG algorithms unreliable
• Majority of SVT management data from selected, younger, lower-comorbidity populations; less evidence in elderly
• Drug recommendations exclude several agents mentioned in 2003 guidelines without direct evidence of inferiority (e.g., sotalol, disopyramide removed from chronic SVT therapy)
• ESC class IIa for IST ivabradine does not represent a definitive change — evidence base remains small RCTs and observational studies

Key Concepts Mentioned

• concepts/SVT-Management — comprehensive acute and chronic management framework; updated recommendation tables
• concepts/AVNRT — epidemiology, ECG diagnosis, ablation outcomes, catheter ablation first-line
• concepts/AVRT-Accessory-Pathway — WPW, antidromic AVRT, pre-excited AF, asymptomatic pre-excitation management
• concepts/Inappropriate-Sinus-Tachycardia — IST pathophysiology, ivabradine Class IIa, catheter ablation not recommended
• concepts/POTS — diagnostic criteria, non-pharmacological first-line, midodrine/beta-blockers/ivabradine
• concepts/Wide-Complex-Tachycardia — ECG criteria favouring VT, default VT assumption, procainamide preferred over amiodarone
• concepts/Tachycardia-Induced-Cardiomyopathy — definition, mechanisms, diagnosis, Class I ablation and beta-blockers

Key Entities Mentioned

• entities/Atrial-Flutter — CTI ablation I/A; ibutilide/dofetilide I for cardioversion; anticoagulation IIa without AF
• entities/Wolff-Parkinson-White-Syndrome — SCD risk stratification, EPS-guided ablation, amiodarone contraindicated in pre-excited AF

Wiki Pages Updated

• wiki/sources/svt-esc-2019.md — created (this file)
• wiki/sourceindex.md — updated
• wiki/wikiindex.md — updated
• wiki/concepts/SVT-Management.md — updated with ESC 2019 data and guideline comparison
• wiki/concepts/AVNRT.md — updated with ESC 2019 ablation outcomes, cryoablation tradeoffs
• wiki/concepts/AVRT-Accessory-Pathway.md — updated with ESC 2019 recommendations; antidromic AVRT; pre-excited AF amiodarone Class III
• wiki/concepts/Inappropriate-Sinus-Tachycardia.md — updated with ESC 2019 ivabradine Class IIa/B; catheter ablation not recommended
• wiki/entities/Atrial-Flutter.md — updated with ESC 2019 recommendations
• wiki/concepts/Wide-Complex-Tachycardia.md — updated with procainamide vs amiodarone; PROCAMIO trial
• wiki/concepts/Tachycardia-Induced-Cardiomyopathy.md — created