Tachycardia Treatment

Treatment

Electrical Cardioversion

Synchronized Electrical Cardioversion

Delivered in time (synchronized) with the QRS complex
Treatment of choice in the acute management of irregular pre-excited tachycardias associated with hemodynamic instability
Recommended in unstable conditions of SVT due to pre-excitation, reentry (AVNRT, AVRT), focal atrial tachycardia, atrial fibrillation, atrial flutter, SVT in adults with congenital heart disease, regular/sustained VT, in the acute management of narrow and persistent wide QRS tachycardia of unknown etiology, or SVT in pregnancy
Recommended in hemodynamically stable patients who are unresponsive or with contraindications to pharmacological therapy
- Recommended in hemodynamically stable patients with AVNRT or with AVRT when unresponsive or with contraindications to vagal maneuvers and Adenosine therapy, with pre-excited atrial fibrillation or SVT in adults with congenital heart disease
Do not attempt electric or pharmacologic cardioversion in patients with atrial fibrillation at risk for cardioemboli, unless the patient is unstable or there is documented absence of left atrial thrombus by transesophageal echocardiogram (TEE)
Shock dose used is lower than dose used for unsynchronized shocks (ie energy used for attempted defibrillation)
Conscious patients should be anesthetized or sedated prior to cardioversion
Cardioversion will not prevent subsequent arrhythmias and can trigger thromboembolism
Serial shocks are inappropriate for self-terminating atrial fibrillation that recur within hours or days (recurrent paroxysmal atrial fibrillation)
Recurrent episodes must be treated with drugs

Recommended Initial Dose for Cardioversion:

Regular narrow-complex tachycardia: 50-100 J
Irregular narrow-complex tachycardia: 120-200 J biphasic or 200 J monophasic
Regular wide-complex tachycardia: 100 J
Irregular wide-complex tachycardia: Unsynchronized defibrillation dose
Atrial fibrillation: 120-200 J with biphasic waveform; 200 J monophasic waveform
Atrial flutter and other SVTs: 50-100 J monophasic damped sine (MDS) waveform
Monophasic ventricular tachycardia (VT): 100 J monophasic waveform
- Increase subsequent shock doses as needed
Polymorphic VT: Treat as ventricular fibrillation with high energy unsynchronized shocks
Low energy (≤100 J biphasic) cardioversion is recommended in hemodynamically stable patients with atrial flutter or macroreentrant atrial arrhythmias for conversion to sinus rhythm

Unsynchronized Electrical Cardioversion

If cardiac rhythm is irregular and it is not possible to synchronize a shock, use high-energy unsynchronized shocks (dose for defibrillation)

Pharmacotherapy

Pharmacotherapy is not recommended for maintenance of sinus rhythm in patients with advanced atrioventricular node dysfunction or sinus node disease unless they have a functioning cardiac pacemaker
Before starting therapy with antiarrhythmic agents, it is recommended to focus treatment on precipitating or reversible causes of atrial fibrillation
- Identify and manage risk factors and concomitant diseases
- Therapy with a particular antiarrhythmic drug is not recommended in patients with atrial fibrillation who have risk factors for proarrhythmia and/or bradycardia with that drug
Hemodynamically stable patients with atrial fibrillation can benefit from pharmacotherapy to maintain sinus rhythm and to prevent tachycardia-induced cardiomyopathy

Adenosine

An endogenous purine nucleotide
More rapid action with fewer side effects than Verapamil in converting SVT
Recommended as the 1st-line drug for the emergency management of hemodynamically stable patients with narrow QRS tachycardia of unknown etiology, if vagal maneuvers fail
- Recommended in the acute management of hemodynamically stable patients with AVNRT, orthodromic AVRT, or in adults with congenital heart disease and with SVT, if vagal maneuvers fail

Should be considered in the acute management of wide QRS tachycardia in the absence of an established diagnosis, if vagal maneuvers fail and there is no pre-excitation on resting ECG
May be used in paroxysmal SVT with reentrant circuits and focal atrial tachycardia
- Used both as therapeutic and diagnostic drug (for atrial flutter and atrial fibrilllation)
- Favorable response to Adenosine favors likelihood of reentry SVT

Also used in stable, wide-complex tachycardias with recurrence of a known reentry pathway
Acts to delay transmission across the AV and sinus node
- May reveal underlying atrial rhythms by slowing the ventricular response in narrow-complex AV nodal or sinus nodal reentry tachycardia

Contraindicated in irregular narrow-complex tachycardias and atrial fibrillation
Contraindicated in unstable or irregular or polymorphic wide-complex tachycardia

Antiarrhythmic Agents - Class Ia

Disopyramide

May be used for sinus rhythm control in patients with vagally mediated atrial fibrillation and with hypertrophic obstructive cardiomyopathy
May be used for patients with VT and premature ventricular contractions

Procainamide HCl

May be used for treatment of stable monomorphic VT in patients with preserved function
May be used for control of cardiac rhythm in atrial fibrillation or atrial flutter in patients with known pre-excitation Wolff-Parkinson White (WPW) syndrome and preserved ventricular function
Should be considered in the acute management of hemodynamically stable patients with antidromic AVRT or with wide QRS tachycardia of unknown etiology, if vagal maneuvers and Adenosine fail or with pre-excited atrial fibrillation
Intravenous (IV) doses may be used for acute junctional tachycardia when treatment with beta-blockers fail
Action: Delays conduction in myocardial tissue

Quinidine

Alternative therapy for sinus rhythm control in patients with atrial fibrillation, when other antiarrhythmic drugs cannot be used
May be used for patients with ventricular tachycardia, ventricular fibrillation, short QT syndrome, and Brugada syndrome unresponsive to beta-blockers or Amiodarone

Antiarrhythmic Agents - Class Ib

Lidocaine

May be considered for, but not the drug of choice for:
- Stable monomorphic VT in patients with preserved ventricular function
- Polymorphic VT with normal baseline QT interval
- Polymorphic VT with a prolonged baseline QT interval that suggests torsades de pointes

Mexiletine

May be used for patients with ventricular tachycardia and long QT syndrome type 3
Treatment option for patients with sustained ventricular tachycardia or after cardiac arrest when unresponsive to Amiodarone therapy

Antiarrhythmic Agents - Class Ic

Flecainide, Propafenone

Recommended for patients with atrial fibrillation for cardiac rate and rhythm control
- Indicated for patients without LV systolic dysfunction, LV hypertrophy or ischemic heart disease
Used for pharmacological cardioversion of patients with atrial flutter or atrial fibrillation
Should be considered in hemodynamically stable patients with antidromic AVRT if vagal maneuvers or Adenosine fail or for prevention of SVT during pregnancy in women with WPW syndrome without structural or ischemic heart disease or when AV nodal blocking agents fail to prevent SVT
May be used for patients with symptomatic SVT (focal atrial tachycardia, AVNRT, AVRT with pre-excited atrial fibrillation, junctional tachycardia), atrial fibrillation, ventricular tachycardia and premature ventricular contractions, or symptomatic recurrent atrial flutter without structural or ischemic heart disease who are not undergoing catheter ablation or those unresponsive/intolerant to beta-blockers and nondihydropyridine calcium antagonists
Oral doses may be considered for chronic orthodromic AVNRT
Contraindicated in adult patients with congenital heart disease with SVT and with ventricular dysfunction and severe fibrosis, or in patients with macroreentrant atrial arrhythmias

Antiarrhythmic Agents - Class III

Amiodarone

Decreases AV conduction and sinus node function
Preferred over other antiarrhythmics for atrial and ventricular arrhythmias in patients who have severely impaired cardiac function
IV doses are recommended for heart rate control in critically-ill atrial fibrillation patients without pre-excitation and in hemodynamically stable patients with focal atrial tachycardia and atrial flutter without pre-excitation and in patients with AVNRT unresponsive or intolerant to other therapies
Treatment of choice for post-operative junctional ectopic tachycardia and for prevention of early junctional ectopic tachycardia in children after open-heart surgery
Recommended antiarrhythmic drug for rhythm control in paroxysmal/persistent atrial fibrillation, including those with heart failure and reduced ejection fraction (HFrEF)
Used in patients with stable narrow-complex regular and irregular tachycardias
Oral doses are used for pharmacological cardioversion of patients with atrial flutter or atrial fibrillation and in chronic orthodromic AVNRT
Should be considered in patients with symptomatic recurrent atrial flutter with heart failure or underlying heart disease
May be used for treatment of stable monomorphic VT, polymorphic VT with normal QT interval, and sustained recurrent monomorphic VT
May be considered in the:
- Acute management of hemodynamically stable patients with wide QRS tachycardia of unknown etiology if vagal maneuvers and Adenosine fail, or with refractory antidromic AVRT
- Chronic management to maintain sinus rhythm in patients with macroreentrant atrial arrhythmias for whom ablation is unsuccessful or unresponsive to beta-blockers or nondihydropyridine calcium channel blockers or to prevent SVT recurrence in adults with congenital heart disease if ablation is not feasible or unsuccessful
- Management of post-op patients to reduce the risk of developing atrial fibrillation
- For acute rate control in atrial fibrillation patients with hemodynamic instability or severely depressed LV ejection fraction (LVEF)
Adrenergic antagonist (alpha and beta)
- Affects sodium, potassium and calcium channels prolonging action potential and refractory period in myocardial tissue
Should not be given to patients with atrial fibrillation with pre-excitation on resting ECG or SVT in pregnant women
Should not be given as long-term rate control for patients with atrial fibrillation

Dofetilide

Recommended for patients with atrial fibrillation for cardiac rate and rhythm control
Used for pharmacological cardioversion of patients with atrial fibrillation or atrial flutter to control rhythm
May also be used for patients with symptomatic SVT (AVNRT, AVRT with or without pre-excited atrial fibrillation) without structural or ischemic heart disease who are not undergoing catheter ablation and unresponsive/intolerant to beta-blockers, Diltiazem, Flecainide, Propafenone, or Verapamil
Not recommended as an outpatient medication; may increase risk of torsades de pointes and altered renal function

Dronedarone

A non-iodinated derivative of Amiodarone, modified to reduce toxicities associated with Amiodarone use
Approved treatment option for clinically stable patients with history of, or current non-permanent atrial fibrillation, to prevent recurrence of atrial fibrillation and to lower ventricular rate
Also recommended for maintenance of sinus rhythm post-cardioversion in patients with paroxysmal/persistent atrial fibrillation unresponsive to first-line agents, without left ventricular systolic dysfunction and previous or current heart failure, and with at least one of the following: diabetes mellitus, hypertension with ongoing 2 maintenance therapies, history of transient ischemic attack, cerebrovascular accident or ischemic attack/stroke/systemic embolism, left atrial diameter of >50 mm, or age >70 years
Patients receiving Dronedarone should receive appropriate antithrombotic treatment
Has been shown to prolong the time to recurrence, slow ventricular rate, improve cardiac rate during exercise and reduce hospitalizations in patients with atrial fibrillation
Patients with permanent atrial fibrillation should not be given Dronedarone due to increased risk of serious cardiovascular events (eg death, stroke, heart failure)
Inhibits potassium currents, thus prolonging cardiac action potential and refractory periods (Class III); inhibits sodium currents (Class Ib) and calcium currents (Class IV); also inhibits adrenergic activities non-competitively (Class II)

Ibutilide

IV doses are recommended for conversion to sinus rhythm of hemodynamically stable patients with atrial flutter or macroreentrant atrial arrhythmias
Should be considered in patients with antidromic AVRT if vagal maneuvers or Adenosine fail or with pre-excited atrial fibrillation
Used for rate control in atrial fibrillation or atrial flutter in patients with preserved ventricular function unresponsive to Calcium antagonists or beta-blockers
- May be considered for termination of atrial flutter during pregnancy
May be used for acute rhythm conversion of atrial fibrillation of ≤48 hours duration in patients with normal cardiac function, with WPW syndrome and preserved ventricular function
May be used to restore sinus rhythm in hemodynamically stable patients with focal atrial tachycardia
Increases the duration of action potential and prolongs the refractory period of cardiac tissue

Anticoagulants

Recommended for atrial fibrillation patients at high risk for systemic embolism and stroke
- Recommended in patients with atrial fibrillation and chronic coronary syndrome (CCS) to prevent ischemic stroke and other ischemic events
Recommended in patients with atrial flutter with concomitant atrial fibrillation
- Should also be considered in patients with atrial flutter without atrial fibrillation
Assess for the presence of risk factors [bleeding, past medical history of stroke, TIA or systemic embolism, CHA₂DS₂-VASc score of ≥2, LVEF <40%, symptomatic heart failure, ≥75 years of age or >65 years with comorbidities] prior to initiation of anticoagulant therapy
Anticoagulation in patients experiencing atrial flutter/atrial fibrillation for <48 hours depend upon the thromboembolic risk
- IV Heparin, low-molecular-weight Heparin (LMWH), or non-vitamin K antagonist oral anticoagulants (NOACs) is recommended for patients with high stroke risk
- Cardioversion with IV Heparin, LMWH, or NOACs or no antithrombotics may be considered for patients with low thromboembolic risk
- Treatment duration of at least 4 weeks is recommended for patients who experienced atrial fibrillation for >24 hours and have undergone cardioversion
Anticoagulation with VKA or direct factor Xa inhibitor for ≥3 weeks before cardioversion and ≥4 weeks after cardioversion is recommended in patients with atrial fibrillation or atrial flutter of ≥48 hours duration or when duration is unknown regardless of the CHA₂DS₂-VASc score
Long-term therapy with oral anticoagulants [NOAC or VKA with time in therapeutic range (TTR) >70%] is recommended in all patients with atrial fibrillation and CHA₂DS₂-VASc score of ≥2 in males and ≥3 in females and should be considered for prevention of stroke in patients with atrial fibrillation and a CHA₂DS₂-VASc score of 1 in males and 2 in females
Anticoagulation with direct acting oral anticoagulants may be offered to patients with atrial fibrillation and a CHA₂DS₂-VASc score of ≥2 and considered in men with atrial fibrillation and a CHA₂DS₂-VASc score of 1, but should also consider the risk of bleeding
Early discontinuation of Aspirin and continued therapy with an oral anticoagulant and a P2Y12 inhibitor (preferably Clopidogrel) for up to 12 months is recommended in patients with atrial fibrillation and acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) who are at low risk for stent thrombosis and at risk for bleeding
For those with CCS, early discontinuation of Aspirin and continued therapy with an oral anticoagulant and Clopidogrel for up to 6 months post-PCI is recommended in patients at low risk for stent thrombosis but at risk for bleeding
Systemic anticoagulation therapy should be continued for at least 2 months after catheter ablation or beyond based on patient's risk for systemic embolism and stroke
Should be used with caution when used concomitantly with nondihydropyridine calcium antagonists and antiplatelet therapy

Non-vitamin K Antagonist Oral Anticoagulants (NOACs)

Eg Apixaban, Dabigatran, Edoxaban, Rivaroxaban
Newer anticoagulants preferred over vitamin K antagonists (VKAs) for their lesser adverse effects and rapid onset of action
- In patients with heart failure, direct-acting oral anticoagulants are recommended in preference to VKAs except in those with mechanical prosthetic heart valves or moderate or severe mitral stenosis
- A study showed that the risk of GI bleeding with Dabigatran compared to Warfarin increased with age
Preferred anticoagulants for stroke prevention in atrial fibrillation
- Dabigatran (a direct thrombin inhibitor), Apixaban, Edoxaban, and Rivaroxaban (direct factor Xa inhibitors) are approved for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation with ≥1 risk factors
Alternative treatment for patients unable to tolerate the side effects of VKAs or to undergo international normalized ratio (INR) monitoring
- Patients on VKA with low TTR of <70% may switch to NOAC
- Good adherence and persistence to therapy should be ensured

Vitamin K Antagonists (VKAs)

Eg Warfarin
Prophylactic treatment of choice for patients with atrial fibrillation with mechanical heart valves and atrial flutter
INR monitoring weekly at the start of treatment and monthly thereafter is required during treatment
- VKAs are safe and effective at adequate TTR of >70%

Beta-Blockers (Antiarrhythmic Agents - Class II)

Eg Atenolol, Bisoprolol, Carvedilol, Esmolol, Labetalol, Metoprolol, Nadolol, Nebivolol, Propranolol
Used in hemodynamically stable patients with preserved ventricular function and narrow-complex regular tachycardias that originate from a reentry mechanism (reentry SVT, AVNRT, orthodromic AVRT with pre-excitation on resting ECG), an automatic focus (junctional, ectopic or multifocal tachycardia) not controlled by vagal maneuvers and Adenosine, or recurrent polymorphic VTs (torsades de pointes)
Recommended for rate control in patients with atrial fibrillation with LVEF<40% and 1st-line drug for atrial fibrillation patients with LVEF ≥40%
- Should be considered in patients with atrial fibrillation and heart failure for short- and long-term rate control
Recommended for tachycardiomyopathy secondary to AVT when catheter ablation fails or is not feasible
IV doses are recommended for acute atrial fibrillation, symptomatic junctional tachycardia, hemodynamically stable atrial flutter, and left ventricle fascicular ventricular tachycardia; oral doses may be used for rate control in patients with chronic atrial fibrillation and hemodynamically stable atrial flutter
- IV doses should be considered for hemodynamically stable patients with focal atrial tachycardia if therapy with Adenosine fails, with AVNRT, orthodromic AVRT or SVT in adults with congenital heart disease if vagal maneuvers and Adenosine fail, in the absence of decompensated heart failure
- IV beta-1 selective blocker except Atenolol should be considered in the acute conversion of SVT in pregnancy
- IV Metoprolol may be used for rate control in patients with MAT in the absence of pulmonary disease, sinus node dysfunction or AV block
Should be considered for symptomatic patients with IST, for the chronic therapy of patients with focal atrial tachycardia, atrial flutter or macroreentrant tachyarrhythmias, AVNRT, AVRT without signs of pre-excitation on resting ECG, or recurrent focal atrial tachycardia or atrial flutter in adults with congenital heart disease, for whom ablation is undesirable or not suitable, provided these patients have no decompensated heart failure
Selective beta-blocker should be considered in the chronic therapy of symptomatic patients with recurrent MAT
May be used as maintenance therapy in patients with symptomatic IST
Low-dose non-selective beta-blocker may be considered in POTS
Lowers HR and BP; decreases the effects of circulating catecholamines; effective rate-controlling agent
Not to be used in patients with VT, pre-excited atrial fibrillation, or systolic heart failure

Sotalol

Has nonselective beta-blocking actions and antiarrhythmic agent Class III properties
Has been shown to decrease post-operative atrial fibrillation
May be used to control rhythm in atrial fibrillation or atrial flutter ≤48 hours in patients with pre-excitation (WPW) syndrome and preserved ventricular function
May be used in stable monomorphic VT, focal atrial tachycardia, and in patients with symptomatic SVT (AVNRT, AVRT with or without pre-excited atrial fibrillation) who are not undergoing catheter ablation
May be an option to prevent recurrent atrial fibrillation
Can be used in patients with ischemic heart disease or structural disease unlike Flecainide and Propafenone
Contraindicated in adults with congenital heart disease and SVT
Action: Prolongs the duration of action potential and increases cardiac tissue refractoriness

Digoxin

Alternative agent for rate control
- Considered when ventricular rate remains high despite beta-blocker therapy or when beta-blockers are not tolerated or contraindicated
Recommended for rate control of atrial fibrillation patients with LVEF <40%
May be useful in patients with systolic CHF or hypotension in whom beta-blockers and Calcium channel blockers are contraindicated and in patients with symptomatic SVT without pre-excitation who prefer not to undergo or are not qualified for catheter ablation
- Should be considered for rate control of atrial tachycardia in pregnant women without WPW syndrome if unresponsive to beta-blocker
Combination with other agents is often necessary to achieve adequate rate control
Exerts positive inotropic effect without lowering BP
Should not be given to patients with AVRT or atrial fibrillation with pre-excitation on resting ECG

Ivabradine

Should be considered in patients with IST to help control sinus rate and IST symptoms
Can be combined with a beta-blocker to manage patients with IST
As monotherapy, may be considered in the treatment of POTS, and in combination with a beta-blocker, may be considered for chronic therapy of focal atrial tachycardia
Inhibits If channels for normal sinus node automaticity

Magnesium

Recommended for the treatment of torsades de pointes VT with or without cardiac arrest

Nondihydropyridine Calcium Antagonists (Antiarrhythmic Agents - Class IV)

Eg Verapamil, Diltiazem
Terminates reentrant arrhythmias and control ventricular response in atrial (focal and multifocal) tachycardias
- Control cardiac rate in patient with preserved ventricular function and atrial fibrillation or atrial flutter when the duration of the arrhythmia is <48 hours
  - Recommended 1st-line drug for rate control in patients with atrial fibrillation with LVEF ≥40%
  - Improves symptoms related to atrial fibrillation compared with beta-blockers
- Treatment option for patients with MAT and pulmonary disease
Used in stable regular narrow-complex tachycardias that failed to convert or uncontrolled by Adenosine or vagal maneuvers
Verapamil must be given only to hemodynamically stable patients with narrow-complex reentry/paroxysmal SVT, arrhythmias of supraventricular origin, and for acute ventricular rate control in patients with atrial fibrillation
IV Verapamil is recommended for patients with left ventricular fascicular ventricular tachycardia
Oral doses are recommended for patients with AVNRT who are not undergoing catheter ablation
IV doses should be considered in the acute therapy of hemodynamically stable patients with focal atrial tachycardia if Adenosine fails, with atrial flutter/macroreentrant atrial tachyarrhythmias, AVNRT, orthodromic AVRT or SVT in adults with congenital heart disease if vagal maneuvers or Adenosine fail and patients with acute junctional tachycardia, in the absence of hypotension or HFrEF
Verapamil or Diltiazem should be considered in the chronic therapy of patients with focal atrial tachycardia, atrial flutter or macroreentrant atrial tachyarrhythmias, with AVNRT, or AVRT without signs of pre-excitation on resting ECG, for whom catheter ablation is undesirable or not suitable, or for symptomatic patients with recurrent MAT, provided these patients have no HFrEF
May be considered for patients with acute orthodromic AVRT with pre-excitation on resting ECG if unresponsive to other treatments, or junctional tachycardia as initial therapy if unresponsive to beta blockers or in symptomatic patients with SANRT without HFrEF
Delay conduction and increase refractoriness in the AV node
Avoid use in patients with left ventricular systolic dysfunction, pre-excited atrial fibrillation, and decompensated heart failure

Vernakalant

Inhibits both atrial sodium and potassium repolarizing currents; classified as both antiarrhythmic agent Class I and III
IV doses may be used for pharmacological cardioversion in hemodynamically stable recent-onset atrial fibrillation patients with coronary artery disease or mild heart failure

Non-Pharmacological Therapy

Vagal maneuvers alone will terminate up to 25% of reentry SVT
- Techniques used to stimulate the receptors in the internal carotid arteries, which cause reflex stimulation of the vagus nerve and result in the release of acetylcholine, which in turn slows down the electrical impulse through the AV node leading to slowing of the heart rate
- Treatment of choice for the acute management of SVT
- Can be used as both diagnostic and therapeutic method to terminate an episode of narrow QRS SVT
- Recommended in the acute management of hemodynamically stable patients with narrow or wide QRS tachycardia of unknown etiology, AVNRT, AVRT, SVT in adults with congenital heart disease, or SVT in pregnancy
Record an ECG during each vagal maneuver
If cardiac rhythm exhibits atrial flutter, slowing of the ventricular response will occur with vagal maneuver and display flutter waves
Vagal maneuvers (or Adenosine) often will suppress AVNRT and orthodromic AVRT within seconds

Valsalva Maneuver

Forced expiration against a closed glottis raises intrathoracic pressure to at least 30-40 mmHg
- When done in the supine position may be most efficacious
Stimulation of the baroreceptors in the aorta induces vagal nerve stimulation and halt of sympathetic stimulation, which leads to a decrease in sinoatrial node activity and AV node conduction
Internationally recommended first-line emergency management for SVT
Found to be more effective in adults, and in patients with AVRT rather than AVNRT

Carotid Sinus Massage

5-10 seconds pressure with circular motion applied on the carotid artery (1 side) at the level of the cricoid cartilage
Contraindicated in patients with carotid artery disease, prior stroke or carotid bruit on examination
Use with caution in the elderly
Stimulates the baroreceptors resulting in a reflex increase in vagus nerve activity
Slows AV node conduction

Lifestyle Modification

Avoidance of stimulants such as caffeine, alcohol, tobacco, medications (cough and cold preparations, beta-agonists), and recreational drugs (amphetamine, cocaine) may help prevent recurrence of sinus tachycardia
Appropriate hydration is encouraged for patients with signs of dehydration or febrile states
Weight loss is recommended especially for obese patients with atrial fibrillation being evaluated for ablation
Exercise training, in addition to the above interventions, should be considered in the management of IST and atrial fibrillation, with the exception of excessive endurance exercise
Patients with hypertension should have good BP control to decrease risk of stroke and bleeding and recurrences of atrial fibrillation
Application of an ice pack on the face may also help relieve symptoms but further studies are needed to prove its use in tachyarrhythmias

Ablation

Treatment option for patients who experience treatment failure after pharmacological therapies or for patients with paroxysmal atrial fibrillation who prefer interventional treatment
Recommended for patients with atrial fibrillation when tachycardia-induced cardiomyopathy is high probable, regardless of symptoms, in order to reverse LV dysfunction
Catheter ablation is preferred over surgical ablation because of significantly increased complications after surgical ablation
Patients on anticoagulant therapy should be assessed for bleeding risk prior to interruption of treatment preprocedurally
- Interruption of anticoagulant therapy is not necessary in patients with no clinically significant or low bleeding risk and without patient-related factors that may increase bleeding risk
- Interruption of oral anticoagulant therapy for the performance of catheter ablation in patients with atrial fibrillation is not recommended in those anticoagulated with NOAC or Warfarin
- May interrupt therapy if patient has intermediate, high, or uncertain bleeding risk, and with patient-related factors that may increase bleeding risk
  - Duration of VKA therapy interruption depends on the patient's INR level
  - Duration of NOAC therapy interruption depends on the patient's bleeding risk, NOAC used, and estimated creatinine clearance
- Establish hemostasis prior to restarting anticoagulant therapy for any invasive procedure

Catheter Ablation

Treatment of choice for recurrent focal atrial tachycardia especially if persistent or causing tachycardiomyopathy, or for symptomatic patients with recurrent AVRT or pre-excited atrial fibrillation
Strongly recommended in symptomatic patients with PJRT or patients with PJRT with impaired LVEF secondary to tachycardiomyopathy
Recommended 1st-line treatment for patients with symptomatic, recurrent AVNRT using the slow-pathway technique and to reverse LV dysfunction in patients with atrial fibrillation with high probability of tachycardia-induced cardiomyopathy regardless of symptoms
Recommended for rhythm control in patients with paroxysmal atrial fibrillation or persistent atrial fibrillation with or without major risk factors for recurrence, unresponsive or intolerant to ≥1 Class I or Class III antiarrhythmic agents
Recommended in asymptomatic patients with high-risk features (eg shortest pre-excited RR interval during atrial fibrillation ≤250 milliseconds, accessory pathway effective refractory period ≤250 milliseconds, multiple accessory pathways, inducible accessory pathway-mediated tachycardia) identified during electrophysiologic testing using Isoprenaline or in high-risk patients with asymptomatic pre-excitation
- Should be considered in patients with atrial fibrillation and heart failure with reduced LVEF
Recommended in symptomatic patients with focal atrial tachycardia, recurrent episodes of CTI-dependent atrial flutter or non-CTI-dependent atrial flutter, persistent atrial flutter or in the presence of depressed left ventricular systolic function due to tachycardiomyopathy, tachycardiomyopathy secondary to SVT, in symptomatic women with recurrent SVT and planning to get pregnant, or in symptomatic athletes with ventricular pre-excitation
Recommended for patients with scar-related cardiac disease with incessant VT, or ischemic heart disease and recurrent implantable cardioverter defibrillator (ICD) shocks due to sustained VT or for patients with VT and unresponsive or intolerant to antiarrhythmic agents or refused antiarrhythmic agents
- May be considered in patients with ischemic heart disease and ICD after first episode of sustained ventricular tachycardia
Should be considered in patients with asymptomatic pre-excitation and left ventricular dysfunction from electrical dyssynchrony, in symptomatic patients with SANRT unresponsive to pharmacological therapy, patients with SVT and adult congenital heart disease undergoing cardiac surgery, patients with symptomatic or recurrent atrial flutter, or in short-coupled torsades de pointes
May be considered in patients with asymptomatic pre-excitation and low-risk accessory pathway identified during invasive or non-invasive risk stratification, or in patients with junctional tachycardia when pharmacological therapy is contraindicated or ineffective
Patients with chronic AVNRT and patients with WPW syndrome may benefit from catheter ablation of the accessory pathway

Balloon Catheter Ablation

Eg cryoballoon ablation, laser balloon ablation
May be considered for symptomatic paroxysmal or persistent atrial fibrillation, if radiofrequency ablation is unsuitable

Surgical Ablation

May be considered in patients with severe cases of IST, ventricular tachycardia, paroxysmal or persistent atrial fibrillation refractory or intolerant to Class I or III antiarrhythmic agents and in atrial fibrillation/atrial flutter patients with adult congenital heart disease undergoing scheduled surgical repair
May be done during cardiac surgery in patients with persistent ventricular tachycardia/flutter even after catheter ablation

Radiofrequency Ablation

Used to reduce sinus rate in patients with IST
Most commonly used electrical ablation source for symptomatic paroxysmal or persistent atrial fibrillation
May be used in patients with recurrent ventricular tachycardia and ventricular fibrillation, followed by ICD implantation, despite pharmacological treatment and/or revascularization

Atrioventricular (AV) Node/Junction Ablation and Pacemaker Implantation

Recommended in patients with tachycardia causing tachycardiomyopathy which cannot be ablated or controlled by drugs
Should be considered in patients with left ventricular dysfunction due to recurrent MAT refractory to pharmacological therapy, in patients with symptomatic persistent macroreentrant atrial tachyarrhythmias with fast ventricular rates unresponsive to pharmacological therapy or ablation or for rate control of patients with atrial fibrillation unresponsive or intolerant to intensive pharmacological rate and rhythm control therapy and not eligible for rhythm control by left atrial ablation
Cardiac resynchronization therapy (CRT) is recommended in patients with symptomatic atrial fibrillation with uncontrolled heart rate regardless of QRS duration and with HFrEF and are candidates for AV junction ablation
- CRT should be considered in patients with permanent or persistent atrial fibrillation with intrinsic QRS ≥130 milliseconds and with HFrEF (NYHA Class III or IV) when ablation is not possible or refused by the patient
Combination therapy with AV junction ablation and CRT may be considered in patients with symptomatic permanent atrial fibrillation despite pharmacological treatments and other interventions with ≥1 hospitalization for CHF or left ventricular dysfunction secondary to high ventricular rates
Results in complete AV nodal blockage

Implantable Cardioverter Defibrillator (ICD)

Recommended in patients with documented ventricular fibrillation or hemodynamically unstable ventricular tachycardia
May be considered in patients with recurrent sustained ventricular tachycardia >48 hours after MI
- Reduces the risk of sudden cardiac death in patients with symptomatic heart failure, left ventricular dysfunction, and heart transplant candidates
Defibrillator with CRT (CRT-D) is recommended for patients who are candidates for an ICD and with indication for CRT
Implantation may be commenced subcutaneously or via transvenous route
External defibrillators (wearable cardioverter defibrillators) should be considered in patients with poor left ventricular systolic function at increased risk of sudden arrhythmic death who cannot tolerate implantable types of defibrillators

Overdrive Pacing (Anti-Tachycardia Pacing)

For patients with an implantable cardiac device
High rate atrial pacing is recommended for termination of atrial flutter or macroreentrant atrial arrhythmias
May be considered in patients with focal atrial tachycardia and recurrent atrial tachycardia, refractory ventricular tachycardia with enhanced automaticity, Digoxin-induced tachycardia, and torsades de pointes to prevent recurrences
May be considered in recurrent ventricular tachycardia unresponsive to pharmacological therapy and catheter ablation
- Produces better prognosis compared to treatment with antiarrhythmic agents

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