The following are key points to remember from the 2019 European Society of Cardiology (ESC) guidelines for the management of patients with supraventricular tachycardia (SVT):

1. This is the first guideline update for SVT by ESC in 16 years. Amiodarone and digoxin are no longer mentioned in the new guidelines for the acute management of narrow complex tachycardia. Sotalol and lidocaine have been removed from the acute management of wide complex tachycardia algorithm.
2. Verapamil/diltiazem and catheter ablation are no longer recommended for inappropriate sinus tachycardia. Ivabradine alone, beta-blocker alone, or both agents taken together should now be considered in symptomatic patients (Class IIa).
3. Procainamide, sotalol, and digoxin are no longer recommended for the acute management of focal atrial tachycardia (AT). Amiodarone, sotalol, and disopyramide are not recommended for chronic suppression of focal AT. Catheter ablation is recommended for recurrent focal AT, especially if incessant or causing tachycardia cardiomyopathy. Beta-blockers should be considered for recurrent focal AT or atrial flutter, if ablation is not possible or successful.
4. For multifocal AT, treatment of an underlying condition is recommended as a first step (Class I). Verapamil, diltiazem, or a selective beta-blocker should be considered (Class IIa). Atrioventricular (AV) nodal ablation followed by biventricular or His-bundle pacing should be considered for patients with left ventricular dysfunction due to recurrent multifocal AT refractory to drug therapy (Class IIa).
5. Dofetilide, sotalol, flecainide, propafenone, procainamide, quinidine, and disopyramide are no longer recommended for chronic management of atrial flutter in the new guidelines. Patients with atrial flutter without atrial fibrillation (AF) should be considered for anticoagulation, but the threshold for initiation is not established (Class IIa).
6. In all re-entrant and most focal arrhythmias, catheter ablation should be offered as an initial choice to patients, after having explained in detail the potential risks and benefits. In post-AF ablation ATs, focal or macro–re-entrant, ablation should be deferred for >3 months after AF ablation, when possible.
7. Multiple drugs have been removed from both the acute and chronic management of AV nodal re-entrant tachycardia (AVNRT). Verapamil, diltiazem, and beta-blockers remain as options for the chronic management of AVNRT, but they were downgraded from Class I to Class IIa.
8. Catheter ablation is recommended in asymptomatic patients in whom electrophysiology testing with the use of isoprenaline identifies high-risk properties, such as shortest pre-excited RR interval during AF ≤250 ms, accessory pathway effective refractory period <250 ms, multiple accessory pathways, and an inducible accessory pathway-mediated tachycardia (Class I). Noninvasive evaluation of the conducting properties of the accessory pathway in individuals with asymptomatic pre-excitation may be considered (Class IIb). Digoxin, beta-blockers, diltiazem, verapamil, and amiodarone are not recommended and are potentially harmful in patients with pre-excited AF (Class III).
9. Sotalol, propranolol, quinidine, and procainamide are no longer used in the updated guidelines for SVT management in pregnant women. During the first trimester, it is recommended that all antiarrhythmic drugs are avoided. Beta-1 selective blockers (except atenolol) or verapamil should be considered for prevention of SVT in patients without Wolff-Parkinson-White (WPW) syndrome (Class IIa). Flecainide or propafenone should be considered for prevention of SVT in patients with WPW syndrome and without ischemic or structural heart disease (Class IIa).
10. SVTs have been reported as risk factors for sudden cardiac death in patients with adult congenital heart disease (ACHD). In ACHD, anticoagulation for focal AT or atrial flutter should be similar to that for patients with AF. Catheter ablation in experienced centers should be considered. Sotalol is not recommended as a first-line antiarrhythmic drug due to an increased risk of proarrhythmia and mortality (Class III). Flecainide and propafenone should be avoided in patients with left bundle branch block, or ischemic or structural heart disease (Class III).
11. In postural orthostatic tachycardia syndrome, a regular and progressive exercise program should be considered (Class IIa). The consumption of up to 2-3 L of water and 10-12 g of sodium chloride daily, as well as midodrine, low-dose nonselective beta-blocker, pyridostigmine, and ivabradine may be considered (Class IIb).

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Exercise

Keywords: Adrenergic beta-Antagonists, Anticoagulants, Anti-Arrhythmia Agents, Arrhythmias, Cardiac, Atrial Fibrillation, Atrial Flutter, Atrioventricular Block, Bundle-Branch Block, Catheter Ablation, Death, Sudden, Cardiac, Electrophysiology, Exercise, Postural Orthostatic Tachycardia Syndrome, Pregnancy, Risk Assessment, Risk Factors, Secondary Prevention, Tachycardia, Atrioventricular Nodal Reentry, Tachycardia, Sinus, Tachycardia, Supraventricular, Ventricular Dysfunction, Left, Wolff-Parkinson-White Syndrome

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