What is the treatment for atrial tachycardia (supraventricular tachycardia)?

From the Guidelines

Treatment of atrial tachycardia should prioritize adenosine as the first-line therapy for acute termination, followed by beta-blockers or calcium channel blockers for rate control and potential conversion, as recommended by the most recent guidelines 1.

Acute Management

For acute termination of atrial tachycardia, the following steps can be taken:

• Vagal maneuvers like carotid sinus massage or Valsalva maneuver can be tried first.
• If these fail, adenosine (6-12 mg IV rapid push) may terminate the arrhythmia, as it is the drug of choice for the acute therapy of SVT when vagal maneuvers fail 1.
• Beta-blockers such as metoprolol (5 mg IV, may repeat up to 15 mg) or calcium channel blockers like diltiazem (0.25 mg/kg IV over 2 minutes) are effective for rate control and potential conversion.

Long-term Management

For long-term management, the following options can be considered:

• Beta-blockers (metoprolol 25-100 mg twice daily) can be used for rate control and prevention of recurrent episodes.
• Calcium channel blockers (diltiazem 120-360 mg daily in divided doses) can also be used for rate control and prevention of recurrent episodes.
• Class IC antiarrhythmics like flecainide (50-200 mg twice daily) can be used for recurrent episodes, but with caution due to potential side effects.
• Catheter ablation is highly effective for definitive treatment with success rates of 90-95% and should be considered for recurrent symptomatic episodes or medication intolerance.

Important Considerations

When treating atrial tachycardia, it is essential to consider the specific mechanism of the tachycardia, patient symptoms, comorbidities, and whether the condition is paroxysmal or persistent. Additionally, caution should be exercised when using AV nodal blocking agents, such as calcium channel blockers and beta-blockers, in patients with pre-excited atrial fibrillation or flutter, as they may accelerate the ventricular response 1.

From the FDA Drug Label

In patients without structural heart disease, flecainide acetate tablets, USP are indicated for the prevention of: •paroxysmal supraventricular tachycardias (PSVT), including atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia and other supraventricular tachycardias of unspecified mechanism associated with disabling symptoms •paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms

Treatment of Atrial Tachycardia:

• Flecainide acetate tablets, USP are indicated for the prevention of paroxysmal supraventricular tachycardias (PSVT), which includes atrial tachycardia, in patients without structural heart disease.
• Propafenone (PO) also reduced the rate of paroxysmal supraventricular arrhythmias, including PSVT, in clinical trials 2.
• The treatment should be initiated under the guidance of a physician, considering the benefits and risks of the treatment, especially due to the proarrhythmic effects of these medications 3.

From the Research

Treatment Options for Atrial Tachycardia

• Vagal maneuvers may be used to terminate the arrhythmia 4
• Adenosine is effective in the acute setting, but may have negative short-term side effects such as flushing or chest discomfort 4, 5
• Calcium channel blockers (diltiazem or verapamil) can be used acutely or as long-term therapy, and may be as effective as adenosine without the negative side effects 4, 5
• Beta blockers (metoprolol) can be used acutely or as long-term therapy, but may have lower efficacy 4, 5
• Class Ic antiarrhythmics (flecainide or propafenone) can be used long-term 4
• Class Ia antiarrhythmics (quinidine, procainamide, or disopyramide) are used less often due to their modest effectiveness and adverse effects 4
• Class III antiarrhythmics (amiodarone, sotalol, or dofetilide) are effective, but have potential adverse effects and should be administered in consultation with a cardiologist 4
• Catheter ablation has a success rate of 95% and recurrence rate of less than 5%, and may be a preferred treatment option for symptomatic patients 4, 6

Diagnosis and Management

• A Holter monitor or event recorder may be needed to confirm the diagnosis of atrial tachycardia 4
• The history is important to elicit episodic symptoms, as physical examination and electrocardiography findings may be normal 4
• Mapping and radiofrequency ablation techniques may be used to treat focal atrial tachycardia 6
• Correction of underlying abnormalities, such as hypokalaemia or hypomagnesaemia, is also required to manage supraventricular and ventricular tachycardias 7