From the Guidelines
Atrial tachycardia should be managed with intravenous beta blockers, diltiazem, or verapamil for acute treatment in hemodynamically stable patients, as recommended by the 2015 ACC/AHA/HRS guideline 1.
Key Recommendations
- For acute termination in stable patients, intravenous beta blockers, diltiazem, or verapamil are recommended 1.
- Synchronized cardioversion is recommended for acute treatment in patients with hemodynamically unstable focal atrial tachycardia 1.
- Adenosine can be useful in the acute setting to either restore sinus rhythm or diagnose the tachycardia mechanism in patients with suspected focal atrial tachycardia 1.
Long-term Management
- For long-term management, options include beta-blockers, calcium channel blockers, or class IC antiarrhythmics like flecainide in patients without structural heart disease.
- Catheter ablation should be considered for recurrent, symptomatic atrial tachycardia resistant to medications, with success rates exceeding 90% 1.
Mechanism and Symptoms
- The mechanism involves abnormal automaticity, triggered activity, or micro-reentry circuits in the atria, which disrupt normal cardiac conduction and can lead to symptoms including palpitations, shortness of breath, chest discomfort, dizziness, or fatigue.
Important Considerations
- The role of ablation in the treatment of atrial fibrillation is still primarily restricted to AV node ablation and pacemaker implantation when medical therapy is not successful 1.
- Radiofrequency ablation has been applied in the treatment of ventricular tachycardia in ischemic disease, bundle-branch reentry, and idiopathic tachycardia 1.
From the FDA Drug Label
In studies of 225 patients with supraventricular arrhythmia (108 with paroxysmal supraventricular tachycardia and 117 with paroxysmal atrial fibrillation), there were 9 (4%) proarrhythmic events, 8 of them in patients with paroxysmal atrial fibrillation Of the 9,7 (including the one in a PSVT patient) were exacerbations of supraventricular arrhythmias (longer duration, more rapid rate, harder to reverse)
The use of flecainide may cause proarrhythmic effects, including new or worsened supraventricular arrhythmias, such as atrial tachycardia.
- The incidence of proarrhythmic events was 4% in patients with supraventricular arrhythmia.
- Most proarrhythmic events (7 out of 9) were exacerbations of supraventricular arrhythmias. 2
From the Research
Atrial Tachycardia
- Atrial fibrillation (AF) is the most common form of sustained arrhythmia, associated with a high risk of embolic complications, tachycardia-related ventricular dysfunction, and disabling symptoms 3.
- The treatment of AF includes pharmacologic therapy to restore and maintain sinus rhythm, prevent recurrences, or control ventricular response rate 3.
- Options for rate control in AF include beta-blockers, nondihydropyridine calcium channel blockers, and digoxin 3, 4, 5, 6, 7.
Rate Control Strategies
- Beta-blockers and calcium channel blockers are commonly used for rate control in AF, with the selection between these two medications depending on personal preference 5.
- Studies have compared the efficacy of beta-blockers and calcium channel blockers in achieving rate control in AF, with some showing that beta-blockers may be more potent for rapid reduction of heart rate 5.
- However, other studies have found that calcium channel blockers may be associated with less bradycardia during sinus rhythm compared to beta-blockers 6.
- The use of concomitant parenteral calcium channel blockers and beta blockers in rapid AF or flutter has also been evaluated, with findings suggesting that this combination can be effective in achieving rate control without increasing the risk of bradycardia 7.
Treatment Outcomes
- The choice of antiarrhythmic drug for AF treatment depends on the presence or absence of structural heart disease, as well as the specific channels blocked by the agent 3.
- Anticoagulant therapy should be considered in patients with AF who are at high risk for embolization 3.
- The ultimate goal of AF treatment is to improve symptoms, prevent complications, and improve quality of life, with the choice of treatment strategy depending on individual patient characteristics and needs 3, 4, 5, 6, 7.