What are the treatment options for atrial tachycardia (supraventricular tachycardia)?

From the Guidelines

Atrial tachycardia treatment should prioritize intravenous beta blockers, diltiazem, or verapamil for acute management in hemodynamically stable patients, as recommended by the 2015 ACC/AHA/HRS guideline 1. For acute treatment of suspected focal atrial tachycardia, the following options are recommended:

• Intravenous beta blockers, diltiazem, or verapamil are useful for acute treatment in hemodynamically stable patients with focal AT, with a moderate effectiveness in terminating the focal AT or slowing the ventricular rate in approximately 30% to 50% of the patients 1.
• Synchronized cardioversion is recommended for acute treatment in patients with hemodynamically unstable focal AT, with termination of tachycardia expected when a focal AT is of a microreentrant mechanism 1. For long-term management, the following options are considered:
• Catheter ablation is recommended in patients with symptomatic focal AT as an alternative to pharmacological therapy, with success rates exceeding 90% 1.
• Oral beta blockers, diltiazem, or verapamil are reasonable for ongoing management in patients with symptomatic focal AT 1.
• Flecainide or propafenone can be effective for ongoing management in patients without structural heart disease or ischemic heart disease who have focal AT 1. It is essential to identify and address any underlying causes of atrial tachycardia, such as electrolyte abnormalities, hyperthyroidism, or drug toxicity, and to consider anticoagulation based on stroke risk factors using the CHA₂DS₂-VASc score. The choice between rate control and rhythm control strategies depends on symptom severity, patient preference, and comorbidities.

From the FDA Drug Label

Clinical Trials In two randomized, crossover, placebo-controlled, double-blind trials of 60–90 days duration in patients with paroxysmal supraventricular arrhythmias [paroxysmal atrial fibrillation/flutter (PAF), or paroxysmal supraventricular tachycardia (PSVT)], propafenone reduced the rate of both arrhythmias... The patient population in the above trials was 50% male with a mean age of 57. 3 years. Fifty percent of the patients had a diagnosis of PAF and 50% had PSVT. Eighty percent of the patients received 600 mg/day propafenone.

Treatment options for atrial tachycardia (supraventricular tachycardia) include:

• Propafenone (PO) at a dose of 600 mg/day, which has been shown to reduce the rate of paroxysmal supraventricular tachycardia (PSVT) in clinical trials 2 Key points:
• Propafenone was effective in reducing the rate of PSVT in two randomized, crossover, placebo-controlled, double-blind trials
• The majority of patients (80%) received 600 mg/day propafenone
• Propafenone may be considered as a treatment option for patients with atrial tachycardia (supraventricular tachycardia) 2

From the Research

Treatment Options for Atrial Tachycardia (Supraventricular Tachycardia)

• Initial therapies for atrial tachycardia include antiarrhythmic medications and surgery, but with the advent of radiofrequency ablation, there has been a shift toward a primary ablative approach 3
• Vagal maneuvers are recommended as the first-line treatment for supraventricular tachycardia, with the modified Valsalva maneuver being the most effective 4
• If vagal maneuvers fail, adenosine can be used in the acute setting, followed by calcium channel blockers or beta blockers for long-term therapy 5
• Class Ic antiarrhythmics, such as flecainide or propafenone, can be used long-term, while Class Ia antiarrhythmics, such as quinidine or procainamide, are used less often due to their modest effectiveness and adverse effects 5
• Class III antiarrhythmics, such as amiodarone or sotalol, are effective but have potential adverse effects and should be administered in consultation with a cardiologist 5
• Catheter ablation has a high success rate and low recurrence rate, making it a preferred treatment for symptomatic patients with certain types of supraventricular tachycardia 5

Vagal Maneuvers

• Vagal maneuvers, such as the Valsalva maneuver or carotid sinus massage, can increase vagal tone and slow supraventricular tachycardia 6, 7, 4
• The modified Valsalva maneuver has been shown to be the most effective vagal maneuver for converting supraventricular tachycardia to sinus rhythm 4
• Other vagal maneuvers, such as digital rectal exam, have also been reported to convert atrial fibrillation to sinus rhythm in some cases 7