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

From the Guidelines

The treatment for atrial tachycardia (supraventricular tachycardia) should prioritize adenosine as the first-line medication for acute termination, followed by beta-blockers or calcium channel blockers for ongoing management, 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 may be attempted first
• If unsuccessful, adenosine (6-12 mg IV rapid push) can effectively terminate many focal atrial tachycardias by blocking AV nodal conduction, as supported by the 2020 ESC guidelines 1
• For hemodynamically unstable patients, immediate synchronized cardioversion at 50-100 joules is recommended, as stated in the 2016 ACC/AHA/HRS guideline 1

Ongoing Management

For ongoing management, the following medications can be used:

• Beta-blockers such as metoprolol (25-100 mg twice daily) or calcium channel blockers like diltiazem (120-360 mg daily in divided doses) are first-line medications to control rate and potentially suppress the arrhythmia, although their strength of recommendation has been downgraded in the 2020 ESC guidelines 1
• Class IC antiarrhythmics like flecainide (50-150 mg twice daily) or class III agents such as sotalol (80-160 mg twice daily) may be used if there is no structural heart disease, but their use has been downgraded in the 2020 ESC guidelines 1
• Amiodarone (200 mg daily after loading) can be considered for patients with structural heart disease, but its use is no longer recommended for acute management of narrow-QRS tachycardias 1
• Catheter ablation is highly effective (success rates 80-95%) and should be considered for patients with symptomatic, recurrent atrial tachycardia or those intolerant to medications, as it can create scar tissue to interrupt the arrhythmia circuit.

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 2

The treatment for atrial tachycardia (supraventricular tachycardia) is flecainide acetate tablets, USP for the prevention of paroxysmal supraventricular tachycardias (PSVT) in patients without structural heart disease.

• Key points:
  • Flecainide acetate tablets, USP are indicated for the prevention of PSVT.
  • The use of flecainide acetate tablets, USP should be reserved for patients in whom the benefits of treatment outweigh the risks.
  • Flecainide acetate tablets, USP should not be used in patients with recent myocardial infarction.
• Note: The label does not provide information on the treatment of atrial tachycardia (supraventricular tachycardia) but rather the prevention of paroxysmal supraventricular tachycardias (PSVT).

From the Research

Treatment Options for Atrial Tachycardia (Supraventricular Tachycardia)

• The efficacy of antiarrhythmic drugs for long-term management of atrial tachycardia is poorly defined, but is probably limited 3
• Class IC or class I agents may be used in re-entrant atrial tachycardia, and verapamil, beta-blockers or class IC agents in the focal type 3
• If these drugs fail, amiodarone may be tried 3
• Radiofrequency catheter ablation is a promising treatment option with success rates between 80% and 95%, and an acceptably low recurrence and complication rate 3
• Vagal maneuvers and adenosine are the first treatment options for ending stable narrow QRS complex SVTs 4
• Long-acting AV nodal-blocking medications, including nondihydropyridine calcium channel blockers (verapamil and diltiazem), flecainide, or beta-blockers, are employed when adenosine or vagal maneuvers fail 4
• Electricity (synchronized cardioversion) is the preferred form of treatment for unstable patients 4
• Digoxin may be used as an alternative in resource-limited settings for patients with unstable PSVT who refuse electrical cardioversion 4
• Adenosine is the drug of choice in acute management of AVRT in hemodynamically stable children 5
• In adenosine-resistant cases, intravenous flecainide, procainamide, esmolol, propafenone and amiodarone are other treatment options 5
• Verapamil may be used to treat AVRT using a concealed pathway, but should be avoided in infants and in patients with decreased cardiac function 5
• Beta-blockers are the preferred first line drugs for chronic management of AVRT in children 5
• Catheter ablation is the preferred treatment in older children with frequent AVRT, while pharmacologic management is recommended in infants and small children 5
• For acute therapy of maternal and fetal arrhythmias during pregnancy, electrical cardioversion with 50 to 100 J is indicated in all unstable patients 6
• In stable supraventricular tachycardia, the initial therapy includes vagal maneuvers to terminate tachycardias, followed by intravenous adenosine if vagal maneuvers fail 6
• Radiofrequency ablation has become a primary approach for the treatment of focal atrial tachycardia due to the poor efficacy of pharmacological therapy 7