How is atrial tachycardia managed?

From the Guidelines

Atrial tachycardia is best 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. For acute management, the following options are available:

• Intravenous beta blockers, diltiazem, or verapamil are recommended for hemodynamically stable patients with focal atrial tachycardia (AT) 1.
• Synchronized cardioversion is recommended for patients with hemodynamically unstable focal AT 1.
• Adenosine can be useful in the acute setting to either restore sinus rhythm or diagnose the tachycardia mechanism in patients with suspected focal AT 1.
• Intravenous amiodarone or ibutilide may be reasonable in the acute setting to either restore sinus rhythm or slow the ventricular rate in hemodynamically stable patients with focal AT 1.

For long-term management, the following options are available:

• Oral verapamil or diltiazem is reasonable for ongoing management in patients with recurrent symptomatic multifocal atrial tachycardia (MAT) 1.
• Metoprolol is reasonable for ongoing management in patients with recurrent symptomatic MAT 1.
• Catheter ablation is highly effective for definitive treatment, with success rates of 90-95%, and should be considered for recurrent episodes or medication intolerance 1. It is essential to address underlying causes such as hyperthyroidism, electrolyte abnormalities, or stimulant use, and anticoagulation may be necessary based on stroke risk factors, particularly if the patient has atrial fibrillation risk factors or if the tachycardia is persistent.

From the FDA Drug Label

CLINICAL PHARMACOLOGY Flecainide acetate tablets, USP have local anesthetic activity and belong to the membrane stabilizing (Class 1) group of antiarrhythmic agents; they have electrophysiologic effects characteristic of the IC class of antiarrhythmics Flecainide acetate tablets, USP cause a dose-related and plasma-level related decrease in single and multiple PVCs and can suppress recurrence of ventricular tachycardia Flecainide does not usually alter heart rate, although bradycardia and tachycardia have been reported occasionally.

The management of atrial tachycardia may involve the use of antiarrhythmic agents such as flecainide. However, the use of flecainide in patients with atrial fibrillation/flutter is not recommended due to the risk of ventricular pro-arrhythmic effects.

• Key considerations for the management of atrial tachycardia include:
  • The use of flecainide may be considered in certain cases, but with caution and close monitoring.
  • Concomitant negative chronotropic therapy such as digoxin or beta-blockers may be used to lower the risk of complications.
  • The risk of ventricular pro-arrhythmic effects should be carefully weighed against the potential benefits of treatment. 2 2

From the Research

Management of Atrial Tachycardia

Atrial tachycardia, a type of supraventricular tachycardia (SVT), can be managed through various techniques. The approach to management depends on the patient's stability and the specific type of SVT.

Initial Management

• For hemodynamically unstable patients with SVT, electrical cardioversion is the recommended treatment 3.
• If the patient is stable, acute termination of tachycardia can be achieved by vagal maneuvers or medical therapy 3.
• Vagal maneuvers such as the Valsalva maneuver, carotid massage, and ice to the face are commonly used to terminate SVT episodes 3.

Medical Therapy

• Adenosine is often used as a first-line treatment for SVT, but it can have negative short-term side effects such as flushing or chest discomfort 4.
• Nondihydropyridine calcium channel blockers, such as verapamil and diltiazem, may be as effective as adenosine in converting SVT to sinus rhythm, without the negative side effects 4.
• Beta-blockers have been evaluated but should not be used routinely due to lower efficacy 4.

Alternative Treatment Options

• Catheter ablation has been shown to be superior to antiarrhythmic drugs in maintaining sinus rhythm and improving symptoms, exercise capacity, and quality of life in patients with atrial fibrillation 5.
• The addition of verapamil to class IC or III antiarrhythmic drugs can reduce atrial fibrillation recurrences after electrical cardioversion 6.
• Calcium channel blockers can be effective in treating broad-complex tachycardia with right bundle branch block, and may be considered as a first-line treatment in certain cases 7.