How should I treat avascular necrosis (AVN) symptoms?

Treatment of AVNRT (Atrioventricular Nodal Reentrant Tachycardia) Symptoms

Catheter ablation of the slow pathway is the first-line definitive treatment for symptomatic AVNRT, with success rates exceeding 95% and less than 1% risk of AV block. 1

Acute Symptom Management

When patients present with active AVNRT episodes, treatment follows a stepwise approach:

First-Line Acute Interventions

• Vagal maneuvers (Valsalva, carotid massage) should be attempted immediately as they are safe, non-invasive, and often effective 1
• Adenosine IV is the pharmacologic agent of choice for acute termination, with rapid onset and high efficacy 1

Second-Line Acute Options

• IV beta blockers, diltiazem, or verapamil are reasonable alternatives when adenosine fails or is contraindicated in hemodynamically stable patients 1
• Synchronized cardioversion must be performed immediately in hemodynamically unstable patients when vagal maneuvers and adenosine fail 1
• IV amiodarone may be considered when other therapies are ineffective or contraindicated, though this is a lower-tier option 1

Long-Term Management Strategy

Definitive Treatment

Catheter ablation is the recommended definitive therapy for all patients with symptomatic AVNRT, as it is potentially curative and eliminates the need for chronic medication 1. The procedure targets slow-pathway modification with:

• Success rates >95% 1
• <1% risk of AV block 1
• Cryoablation is an alternative to radiofrequency ablation with equivalent acute success but slightly higher recurrence rates during long-term follow-up 1

Medical Management (When Ablation Declined or Not Feasible)

For patients who are not candidates for or decline catheter ablation, pharmacologic options include:

First-line medications:

• Oral verapamil or diltiazem are well-tolerated and effective, but must be avoided in systolic heart failure and monitored for bradyarrhythmias and hypotension 1
• Oral beta blockers are equally recommended as ongoing management 1

Second-line medications:

• Flecainide or propafenone are reasonable in patients without structural heart disease or ischemic heart disease when first-line agents fail 1
• Oral sotalol or dofetilide may be reasonable alternatives 1
• Digoxin or amiodarone may be considered, though evidence is limited 1

Special Considerations

• "Pill-in-the-pocket" approach with oral beta blockers, diltiazem, or verapamil may be reasonable for patients with infrequent, well-tolerated episodes 1
• Clinical follow-up without treatment is reasonable for minimally symptomatic patients 1

Critical Pitfalls to Avoid

• Do not use verapamil or diltiazem in patients with systolic heart failure as these agents can worsen cardiac function 1
• Monitor for bradyarrhythmias and hypotension when initiating calcium channel blockers 1
• Do not use flecainide or propafenone in patients with structural heart disease or ischemic heart disease due to proarrhythmic risk 1
• Recognize that the evidence provided regarding AVN (avascular necrosis) and AVM (arteriovenous malformations) is not relevant to AVNRT treatment and should be disregarded 1, 2, 3, 4, 5, 6, 7, 8, 9