Catheter ablation revolutionises care for supraventricular tachycardias: ESC 2019 update

Catheter ablation revolutionises care for supraventricular tachycardias reveals new guidelines on Supraventricular tachycardia.

The European Society of Cardiology (ESC) has released guidelines on Supraventricular tachycardia. The guidelines have been developed by ESC in collaboration with the Association for European Paediatric and Congenital Cardiology (AEPC). The 2019 ESC guidelines have been published in the European Heart Journal.

Supraventricular tachycardia refers to a heart rate above 100 beats per minute (normal resting heart rate is 60 to 100).SVT occurs when there is a fault with the electric system that controls the heart’s rhythm. SVTs are frequent arrhythmias, with a prevalence of approximately 0.2% in the general population. Women have a risk of developing SVT that is two times greater than men, while people 65 years or older have more than five times the risk of developing SVT than younger people.

SVTs usually start and stop suddenly. They arise in the atria of the heart and the conduction system above the ventricles, and are rarely life-threatening in the acute phase, unlike arrhythmias from the ventricles. However, most SVTs, if left untreated, are lifelong conditions that affect the heart’s function, increase the risk of stroke, and affect the quality of life. Symptoms include palpitations, fatigue, light-headedness, chest discomfort, shortness of breath, and altered consciousness.

The guidelines provide treatment recommendations for all types of SVTs. Drug therapies for SVT have not fundamentally changed since the previous guidelines were published in 2003.

But Professor Josep Brugada, Chairperson of the guidelines Task Force and professor of medicine, University of Barcelona, Spain, said: “We do have more data on the potential benefits and risks associated with several drugs, and we know how to use them in a safer way. In addition, some new antiarrhythmic drugs are available.”

Antiarrhythmic drugs are useful for acute episodes. For long-term treatment, these drugs are of limited value due to relatively low efficacy and related side-effects.

The main change in clinical practice over the last 16 years is related to the availability of more efficient and safe invasive methods for eradication of the arrhythmia through catheter ablation. This therapy uses heat or freezing to destroy the heart tissue causing the arrhythmia.

Professor Demosthenes Katritsis, Chairperson of the guidelines Task Force and director of the 3rdCardiology Department, Hygeia Hospital, Athens, Greece, said: “Catheter ablation techniques and technology have evolved in a way that we can now offer this treatment modality to most of our patients with SVT.”

SVT is linked with a higher risk of complications during pregnancy, and specific recommendations are provided for pregnant women. All antiarrhythmic drugs should be avoided, if possible, within the first trimester of pregnancy. However, if necessary, some drugs may be used with caution during that period.

“Pregnant women with persistent arrhythmias that do not respond to drugs, or for whom drug therapy is contraindicated or not desirable, can now be treated with catheter ablation using new techniques that avoid exposing themselves or their baby to harmful levels of radiation,” said Prof Katritsis.

What should people do if they experience a fast heartbeat? “Always seek medical help and advice if you have a fast heartbeat,” said Prof Brugada. “If SVT is suspected, you should undergo electrophysiology studies with a view to catheter ablation, since several of the underlying conditions may have serious long-term side effects and inadvertently affect your wellbeing. Prevention of recurrences depends on the particular type of SVT, so ask your doctor for advice. Catheter ablation is safe and cures most SVTs.”

Key takeaways from the ESC and AEPC guideline for the management of patients with supraventricular tachycardia are:

• Not all SVTs are arrhythmias of the young.


• Vagal manoeuvres and adenosine are the treatments of choice for the acute therapy of SVT, and may also provide important diagnostic information.


• Verapamil is not recommended in wide QRS-complex tachycardia of unknown aetiology.


• Consider using ivabradine, when indicated, together with a beta-blocker.


• 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.


• Patients with macro−re-entrant tachycardias following atrial surgery should be referred to specialized centres for ablation.


• In post-AF ablation ATs, focal or macro−re-entrant, ablation should be deferred for ≥3 months after AF ablation, when possible.


• Ablate AVNRT, typical or atypical, with lesions in the anatomical area of the nodal extensions, either from the right or left septum.


• AVNRT, typical or atypical, can now be ablated with almost no risk of AV block.


• Do not use sotalol in patients with SVT.


• Do not use flecainide or propafenone in patients with LBBB, or ischaemic or structural heart disease.


• Do not use amiodarone in pre-excited AF.


• One in five patients with asymptomatic pre-excitation will develop an arrhythmia related to their AP during follow-up.


• The risk of cardiac arrest/ventricular fibrillation in a patient with asymptomatic pre-excitation is ∼2.4 per 1000 person-years.


• Non-invasive screening may be used for risk stratification of patients with asymptomatic pre-excitation, but its predictive ability remains modest.


• Invasive assessment with an EPS is recommended in patients with asymptomatic pre-excitation who either have high-risk occupations or are competitive athletes.


• If a patient undergoes assessment with an EPS and is found to have an AP with ‘high-risk’ characteristics, catheter ablation should be performed.


• If possible, avoid all antiarrhythmic drugs during the first trimester of pregnancy. If beta-blockers are necessary, use only beta-1 selective agents (but not atenolol).


• If ablation is necessary during pregnancy, use non-fluoroscopic mapping.


• Consider TCM in patients with reduced LV function and SVT.


• Ablation is the treatment of choice for TCM due to SVT. AV nodal ablation with subsequent biventricular or His-bundle pacing (‘ablate and pace’) should be considered if the SVT cannot be ablated

To read the recommendations in detail follow the link: https://doi.org/10.1093/eurheartj/ehz467