2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia
2015; Lippincott Williams & Wilkins; Volume: 133; Issue: 14 Linguagem: Inglês
10.1161/cir.0000000000000311
ISSN1524-4539
AutoresRichard L. Page, José A. Joglar, Mary A. Caldwell, Hugh Calkins, Jamie B. Conti, Barbara J. Deal, N.A. Mark Estes, Michael E. Field, Zachary D. Goldberger, Stephen C. Hammill, Julia H. Indik, Bruce D. Lindsay, Brian Olshansky, Andrea M. Russo, Win-Kuang Shen, Cynthia M. Tracy, Sana M. Al‐Khatib,
Tópico(s)Atrial Fibrillation Management and Outcomes
ResumoHomeCirculationVol. 133, No. 142015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUB2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular TachycardiaA Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society Richard L. Page, MD, FACC, FAHA, FHRS, Chair José A. Joglar, MD, FACC, FAHA, FHRS, Vice Chair Mary A. Caldwell, RN, MBA, PhD, FAHA Hugh Calkins, MD, FACC, FAHA, FHRS Jamie B. Conti, MD, FACC Barbara J. Deal, MD N.A. Mark EstesIII, MD, FACC, FAHA, FHRS Michael E. Field, MD, FACC, FHRS Zachary D. Goldberger, MD, MS, FACC, FAHA, FHRS Stephen C. Hammill, MD, FACC, FHRS Julia H. Indik, MD, PhD, FACC, FAHA, FHRS Bruce D. Lindsay, MD, FACC, FHRS Brian Olshansky, MD, FACC, FAHA, FHRS Andrea M. Russo, MD, FACC, FHRS Win-Kuang Shen, MD, FACC, FAHA, FHRS Cynthia M. Tracy, and MD, FACC Sana M. Al-KhatibMD, MHS, FACC, FAHA, FHRSEvidence Review Committee Chair‡ Richard L. PageRichard L. Page , José A. JoglarJosé A. Joglar , Mary A. CaldwellMary A. Caldwell , Hugh CalkinsHugh Calkins *, †, ‡, §, ‖, ¶ , Jamie B. ContiJamie B. Conti *, †, ‡, §, ‖, ¶ , Barbara J. DealBarbara J. Deal *, †, ‡, §, ‖, ¶ , N.A. Mark EstesIIIN.A. Mark EstesIII *, †, ‡, §, ‖, ¶ , Michael E. FieldMichael E. Field *, †, ‡, §, ‖, ¶ , Zachary D. GoldbergerZachary D. Goldberger *, †, ‡, §, ‖, ¶ , Stephen C. HammillStephen C. Hammill *, †, ‡, §, ‖, ¶ , Julia H. IndikJulia H. Indik *, †, ‡, §, ‖, ¶ , Bruce D. LindsayBruce D. Lindsay *, †, ‡, §, ‖, ¶ , Brian OlshanskyBrian Olshansky *, †, ‡, §, ‖, ¶ , Andrea M. RussoAndrea M. Russo *, †, ‡, §, ‖, ¶ , Win-Kuang ShenWin-Kuang Shen *, †, ‡, §, ‖, ¶ , Cynthia M. TracyCynthia M. Tracy *, †, ‡, §, ‖, ¶ , and Sana M. Al-KhatibSana M. Al-Khatib and Evidence Review Committee Chair‡ Originally published23 Sep 2015https://doi.org/10.1161/CIR.0000000000000311Circulation. 2016;133:e506–e574is corrected byCorrection to: 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm SocietyOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: September 23, 2015: Previous Version 1 Table of ContentsPreamble e507Introduction e5081.1. Methodology and Evidence Review e5081.2. Organization of the GWC e5101.3. Document Review and Approval e5101.4. Scope of the Guideline e510General Principles e5102.1. Mechanisms and Definitions e5102.2. Epidemiology, Demographics, and Public Health Impact e5102.3. Evaluation of the Patient With Suspected or Documented SVT e5112.3.1. Clinical Presentation and Differential Diagnosis on the Basis of Symptoms e5112.3.2. Evaluation of the ECG e5142.4. Principles of Medical Therapy e5152.4.1. Acute Treatment: Recommendations e5152.4.2. Ongoing Management: Recommendations e5172.5. Basic Principles of Electrophysiological Study, Mapping, and Ablation e5182.5.1. Mapping With Multiple and Roving Electrodes e5182.5.2. Tools to Facilitate Ablation, Including 3-Dimensional Electroanatomic Mapping e5182.5.3. Mapping and Ablation With No or Minimal Radiation e5192.5.4. Ablation Energy Sources e519Sinus Tachyarrhythmias e5203.1. Physiological Sinus Tachycardia e5213.2. Inappropriate Sinus Tachycardia e5213.2.1. Acute Treatment e5213.2.2. Ongoing Management: Recommendations e521Nonsinus Focal Atrial Tachycardia and MAT e5234.1. Focal Atrial Tachycardia e5234.1.1. Acute Treatment: Recommendations e5264.1.2. Ongoing Management: Recommendations e5274.2. Multifocal Atrial Tachycardia e5274.2.1. Acute Treatment: Recommendation e5314.2.2. Ongoing Management: Recommendations e531Atrioventricular Nodal Reentrant Tachycardia e5315.1. Acute Treatment: Recommendations e5325.2. Ongoing Management: Recommendations e533Manifest and Concealed Accessory Pathways e5346.1. Management of Patients With Symptomatic Manifest or Concealed Accessory Pathways e5356.1.1. Acute Treatment: Recommendations e5356.1.2. Ongoing Management: Recommendations e5366.2. Management of Asymptomatic Pre-Excitation e5376.2.1. PICOTS Critical Questions e5376.2.2. Asymptomatic Patients With Pre-Excitation: Recommendations e5386.3. Risk Stratification of Symptomatic Patients With Manifest Accessory Pathways: Recommendations e539Atrial Flutter e5397.1. Cavotricuspid Isthmus–Dependent Atrial Flutter e5397.2. Non–Isthmus-Dependent Atrial Flutters e5407.3. Acute Treatment: Recommendations e5417.4. Ongoing Management: Recommendations e542Junctional Tachycardia e5448.1. Acute Treatment: Recommendations e5448.2. Ongoing Management: Recommendations e545Special Populations e5459.1. Pediatrics e5459.2. Patients With Adult Congenital Heart Disease e5499.2.1. Clinical Features e5499.2.2. Acute Treatment: Recommendations e5509.2.3. Ongoing Management: Recommendations e5519.3. Pregnancy e5539.3.1. Acute Treatment: Recommendations e5539.3.2. Ongoing Management: Recommendations e5549.4. SVT in Older Populations e5559.4.1. Acute Treatment and Ongoing Management: Recommendation e555Quality-of-Life Considerations e555Cost-Effectiveness e555Shared Decision Making e556Evidence Gaps and Future Research Needs e556References e557Appendix 1. Author Relationships With Industry and Other Entities (Relevant) e570Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant) e571Appendix 3. Abbreviations e574PreambleSince 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, based on systematic methods to evaluate and classify evidence, provide a cornerstone of quality cardiovascular care.In response to reports from the Institute of Medicine1,2 and a mandate to evaluate new knowledge and maintain relevance at the point of care, the ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) modified its methodology.3–5 The relationships between guidelines, data standards, appropriate use criteria, and performance measures are addressed elsewhere.4Intended UsePractice guidelines provide recommendations applicable to patients with or at risk of developing cardiovascular disease. The focus is on medical practice in the United States, but guidelines developed in collaboration with other organizations may have a broader target. Although guidelines may inform regulatory or payer decisions, they are intended to improve quality of care in the interest of patients.Evidence ReviewGuideline Writing Committee (GWC) members review the literature; weigh the quality of evidence for or against particular tests, treatments, or procedures; and estimate expected health outcomes. In developing recommendations, the GWC uses evidence-based methodologies that are based on all available data.4–6 Literature searches focus on randomized controlled trials (RCTs) but also include registries, nonrandomized comparative and descriptive studies, case series, cohort studies, systematic reviews, and expert opinion. Only selected references are cited.The Task Force recognizes the need for objective, independent Evidence Review Committees (ERCs) that include methodologists, epidemiologists, clinicians, and biostatisticians who systematically survey, abstract, and assess the evidence to address key clinical questions posed in the PICOTS format (P=population, I=intervention, C=comparator, O=outcome, T=timing, S=setting).4,5 Practical considerations, including time and resource constraints, limit the ERCs to evidence that is relevant to key clinical questions and lends itself to systematic review and analysis that could affect the strength of corresponding recommendations. Recommendations developed by the GWC on the basis of the systematic review are marked "SR".Guideline-Directed Medical TherapyThe term guideline-directed medical therapy refers to care defined mainly by ACC/AHA Class I recommendations. For these and all recommended drug treatment regimens, the reader should confirm dosage with product insert material and carefully evaluate for contraindications and interactions. Recommendations are limited to treatments, drugs, and devices approved for clinical use in the United States.Class of Recommendation and Level of EvidenceThe Class of Recommendation (COR; ie, the strength of the recommendation) encompasses the anticipated magnitude and certainty of benefit in proportion to risk. The Level of Evidence (LOE) rates evidence supporting the effect of the intervention on the basis of the type, quality, quantity, and consistency of data from clinical trials and other reports (Table 1).5,7 Unless otherwise stated, recommendations are sequenced by COR and then by LOE. Where comparative data exist, preferred strategies take precedence. When >1 drug, strategy, or therapy exists within the same COR and LOE and no comparative data are available, options are listed alphabetically. Each recommendation is followed by supplemental text linked to supporting references and evidence tables.Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care*Table 1. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care*Relationships With Industry and Other EntitiesThe ACC and AHA sponsor the guidelines without commercial support, and members volunteer their time. The Task Force zealously avoids actual, potential, or perceived conflicts of interest that might arise through relationships with industry or other entities (RWI). All GWC members and reviewers are required to disclose current industry relationships or personal interests from 12 months before initiation of the writing effort. Management of RWI involves selecting a balanced GWC and assuring that the chair and a majority of committee members have no relevant RWI (Appendix 1). Members are restricted with regard to writing or voting on sections to which their RWI apply. For transparency, members' comprehensive disclosure information is available online. Comprehensive disclosure information for the Task Force is also available online. The Task Force strives to avoid bias by selecting experts from a broad array of backgrounds representing different geographic regions, sexes, ethnicities, intellectual perspectives/biases, and scopes of clinical practice, and by inviting organizations and professional societies with related interests and expertise to participate as partners or collaborators.Individualizing Care in Patients With Associated Conditions and ComorbiditiesManaging patients with multiple conditions can be complex, especially when recommendations applicable to coexisting illnesses are discordant or interacting.8 The guidelines are intended to define practices meeting the needs of patients in most, but not all, circumstances. The recommendations should not replace clinical judgment.Clinical ImplementationManagement in accordance with guideline recommendations is effective only when followed. Adherence to recommendations can be enhanced by shared decision making between clinicians and patients, with patient engagement in selecting interventions based on individual values, preferences, and associated conditions and comorbidities. Consequently, circumstances may arise in which deviations from these guidelines are appropriate.PolicyThe recommendations in this guideline represent the official policy of the ACC and AHA until superseded by published addenda, statements of clarification, focused updates, or revised full-text guidelines. To ensure that guidelines remain current, new data are reviewed biannually to determine whether recommendations should be modified. In general, full revisions are posted in 5-year cycles.3,5Jonathan L. Halperin, MD, FACC, FAHAChair, ACC/AHA Task Force on Clinical Practice Guidelines1. Introduction1.1. Methodology and Evidence ReviewThe recommendations listed in this guideline are, whenever possible, evidence based. An extensive evidence review was conducted in April 2014 that included literature published through September 2014. Other selected references published through May 2015 were incorporated by the GWC. Literature included was derived from research involving human subjects, published in English, and indexed in MEDLINE (through PubMed), EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. The relevant data are included in evidence tables in the Online Data Supplement. Key search words included but were not limited to the following: ablation therapy (catheter and radiofrequency; fast and slow pathway), accessory pathway (manifest and concealed), antiarrhythmic drugs, atrial fibrillation, atrial tachycardia, atrioventricular nodal reentrant (reentry, reciprocating) tachycardia, atrioventricular reentrant (reentry, reciprocating) tachycardia, beta blockers, calcium channel blockers, cardiac imaging, cardioversion, cost effectiveness, cryotherapy, echocardiography, elderly (aged and older), focal atrial tachycardia, Holter monitor, inappropriate sinus tachycardia, junctional tachycardia, multifocal atrial tachycardia, paroxysmal supraventricular tachycardia, permanent form of junctional reciprocating tachycardia, pre-excitation, pregnancy, quality of life, sinoatrial node, sinus node reentry, sinus tachycardia, supraventricular tachycardia, supraventricular arrhythmia, tachycardia, tachyarrhythmia, vagal maneuvers (Valsalva maneuver), and Wolff-Parkinson-White syndrome. Additionally, the GWC reviewed documents related to supraventricular tachycardia (SVT) previously published by the ACC, AHA, and Heart Rhythm Society (HRS). References selected and published in this document are representative and not all-inclusive.An independent ERC was commissioned to perform a systematic review of key clinical questions, the results of which were considered by the GWC for incorporation into this guideline. The systematic review report on the management of asymptomatic patients with Wolff-Parkinson-White (WPW) syndrome is published in conjunction with this guideline.91.2. Organization of the GWCThe GWC consisted of clinicians, cardiologists, electrophysiologists (including those specialized in pediatrics), and a nurse (in the role of patient representative) and included representatives from the ACC, AHA, and HRS.1.3. Document Review and ApprovalThis document was reviewed by 8 official reviewers nominated by the ACC, AHA, and HRS, and 25 individual content reviewers. Reviewers' RWI information was distributed to the GWC and is published in this document (Appendix 2).This document was approved for publication by the governing bodies of the ACC, the AHA, and the HRS.1.4. Scope of the GuidelineThe purpose of this joint ACC/AHA/HRS document is to provide a contemporary guideline for the management of adults with all types of SVT other than atrial fibrillation (AF). Although AF is, strictly speaking, an SVT, the term SVT generally does not refer to AF. AF is addressed in the 2014 ACC/AHA/HRS Guideline for the Management of Atrial Fibrillation (2014 AF guideline).10 The present guideline addresses other SVTs, including regular narrow–QRS complex tachycardias, as well as other, irregular SVTs (eg, atrial flutter with irregular ventricular response and multifocal atrial tachycardia [MAT]). This guideline supersedes the "2003 ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias."11 It incorporates new and existing knowledge derived from published clinical trials, basic science, and comprehensive review articles, along with evolving treatment strategies and new drugs. Some recommendations from the earlier guideline have been updated as warranted by new evidence or a better understanding of existing evidence, whereas other inaccurate, irrelevant, or overlapping recommendations were deleted or modified. Whenever possible, we reference data from the acute clinical care environment; however, in some cases, the reference studies from the invasive electrophysiology laboratory inform our understanding of arrhythmia diagnosis and management. Although this document is aimed at the adult population (≥18 years of age) and offers no specific recommendations for pediatric patients, as per the reference list, we examined literature that included pediatric patients. In some cases, the data from noninfant pediatric patients helped inform this guideline.In the current healthcare environment, cost consideration cannot be isolated from shared decision making and patient-centered care. The AHA and ACC have acknowledged the importance of value in health care, calling for eventual development of a Level of Value for practice recommendations in the "2014 ACC/AHA Statement on Cost/Value Methodology in Clinical Practice Guidelines and Performance Measures."6 Although quality-of-life and cost-effectiveness data were not sufficient to allow for development of specific recommendations, the GWC agreed the data warranted brief discussion (Sections 10 and 11). Throughout this document, and associated with all recommendations and algorithms, the importance of shared decision making should be acknowledged. Each approach, ranging from observation to drug treatment to ablation, must be considered in the setting of a clear discussion with the patient regarding risk, benefit and personal preference. See Section 12 for additional information.In developing this guideline, the GWC reviewed prior published guidelines and related statements. Table 2 contains a list of guidelines and statements deemed pertinent to this writing effort and is intended for use as a resource, thus obviating the need to repeat existing guideline recommendations.Table 2. Associated Guidelines and StatementsTitleOrganizationPublication Year (Reference)Guidelines Atrial fibrillationAHA/ACC/HRS201410 Stable ischemic heart diseaseACC/AHA/ACP/AATS/ PCNA/SCAI/STS201412 201213 Valvular heart diseaseAHA/ACC201414 Assessment of cardiovascular riskACC/AHA201315 Heart failureACC/AHA201316 Antithrombotic therapy for valvular heart diseaseACCP201217 Atrial fibrillationESC201218 201019 Device-based therapyACC/AHA/HRS201220 Atrial fibrillationCCS201421 201122 Hypertrophic cardiomyopathyACC/AHA201123 Secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular diseaseAHA/ACC201124 Adult congenital heart diseaseACC/AHA200825* Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII)NHLBI200326Statements Catheter ablation in children and patients with congenital heart diseasePACES/HRS2015 (in press)27 Postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncopeHRS201528 Arrhythmias in adult congenital heart diseasePACES/HRS201429 Catheter and surgical ablation of atrial fibrillationHRS/EHRA/ECAS201230 CPR and emergency cardiovascular careAHA201031**A revision to the current document is being prepared, with publication expected in late 2015.AATS indicates American Association for Thoracic Surgery; ACC, American College of Cardiology; ACCP, American College of Chest Physicians; ACP, American College of Physicians; AHA, American Heart Association; CCS, Canadian Cardiovascular Society; CPR, cardiopulmonary resuscitation; ECAS, European Cardiac Arrhythmia Society; EHRA, European Heart Rhythm Association; ESC, European Society of Cardiology; HRS, Heart Rhythm Society; JNC, Joint National Committee; NHLBI, National Heart, Lung, and Blood Institute; PACES, Pediatric and Congenital Electrophysiology Society; PCNA, Preventive Cardiovascular Nurses Association; SCAI, Society for Cardiovascular Angiography and Interventions; and STS, Society of Thoracic Surgeons.2. General Principles2.1. Mechanisms and DefinitionsFor the purposes of this guideline, SVT is defined as per Table 3, which provides definitions and the mechanism(s) of each type of SVT. The term SVT does not generally include AF, and this document does not discuss the management of AF.Table 3. Relevant Terms and DefinitionsArrhythmia/TermDefinitionSupraventricular tachycardia (SVT)An umbrella term used to describe tachycardias (atrial and/or ventricular rates in excess of 100 bpm at rest), the mechanism of which involves tissue from the His bundle or above. These SVTs include inappropriate sinus tachycardia, AT (including focal and multifocal AT), macroreentrant AT (including typical atrial flutter), junctional tachycardia, AVNRT, and various forms of accessory pathway-mediated reentrant tachycardias. In this guideline, the term does not include AF.Paroxysmal supraventricular tachycardia (PSVT)A clinical syndrome characterized by the presence of a regular and rapid tachycardia of abrupt onset and termination. These features are characteristic of AVNRT or AVRT, and, less frequently, AT. PSVT represents a subset of SVT.Atrial fibrillation (AF)A supraventricular arrhythmia with uncoordinated atrial activation and, consequently, ineffective atrial contraction. ECG characteristics include: 1) irregular atrial activity, 2) absence of distinct P waves, and 3) irregular R-R intervals (when atrioventricular conduction is present). AF is not addressed in this document.Sinus tachycardiaRhythm arising from the sinus node in which the rate of impulses exceeds 100 bpm. • Physiologic sinus tachycardiaAppropriate increased sinus rate in response to exercise and other situations that increase sympathetic tone. • Inappropriate sinus tachycardiaSinus heart rate >100 bpm at rest, with a mean 24-h heart rate >90 bpm not due to appropriate physiological responses or primary causes such as hyperthyroidism or anemia.Atrial tachycardia (AT) • Focal ATAn SVT arising from a localized atrial site, characterized by regular, organized atrial activity with discrete P waves and typically an isoelectric segment between P waves. At times, irregularity is seen, especially at onset ("warm-up") and termination ("warm-down"). Atrial mapping reveals a focal point of origin. • Sinus node reentry tachycardiaA specific type of focal AT that is due to microreentry arising from the sinus node complex, characterized by abrupt onset and termination, resulting in a P-wave morphology that is indistinguishable from sinus rhythm. • Multifocal atrial tachycardia (MAT)An irregular SVT characterized by ≥3 distinct P-wave morphologies and/or patterns of atrial activation at different rates. The rhythm is always irregular.Atrial flutter • Cavotricuspid isthmus–dependent atrial flutter: typicalMacroreentrant AT propagating around the tricuspid annulus, proceeding superiorly along the atrial septum, inferiorly along the right atrial wall, and through the cavotricuspid isthmus between the tricuspid valve annulus and the Eustachian valve and ridge. This activation sequence produces predominantly negative "sawtooth" flutter waves on the ECG in leads 2, 3, and aVF and a late positive deflection in V1. The atrial rate can be slower than the typical 300 bpm (cycle length 200 ms) in the presence of antiarrhythmic drugs or scarring. It is also known as "typical atrial flutter" or "cavotricuspid isthmus–dependent atrial flutter" or "counterclockwise atrial flutter." • Cavotricuspid isthmus–dependent atrial flutter: reverse typicalMacroreentrant AT that propagates around in the direction reverse that of typical atrial flutter. Flutter waves typically appear positive in the inferior leads and negative in V1. This type of atrial flutter is also referred to as "reverse typical" atrial flutter or "clockwise typical atrial flutter." • Atypical or non–cavotricuspid isthmus–dependent atrial flutterMacroreentrant ATs that do not involve the cavotricuspid isthmus. A variety of reentrant circuits may include reentry around the mitral valve annulus or scar tissue within the left or right atrium. A variety of terms have been applied to these arrhythmias according to the re-entry circuit location, including particular forms, such as "LA flutter" and "LA macroreentrant tachycardia" or incisional atrial re-entrant tachycardia due to re-entry around surgical scars.Junctional tachycardiaA nonreentrant SVT that arises from the AV junction (including the His bundle).Atrioventricular nodal reentrant tachycardia (AVNRT)A reentrant tachycardia involving 2 functionally distinct pathways, generally referred to as "fast" and "slow" pathways. Most commonly, the fast pathway is located near the apex of Koch's triangle, and the slow pathway inferoposterior to the compact AV node tissue. Variant pathways have been described, allowing for "slow-slow" AVNRT. • Typical AVNRTAVNRT in which a slow pathway serves as the anterograde limb of the circuit and the fast pathway serves as the retrograde limb (also called "slow-fast AVNRT"). • Atypical AVNRTAVNRT in which the fast pathway serves as the anterograde limb of the circuit and a slow pathway serves as the retrograde limb (also called "fast-slow AV node reentry") or a slow pathway serves as the anterograde limb and a second slow pathway serves as the retrograde limb (also called "slow-slow AVNRT").Accessory pathwayFor the purpose of this guideline, an accessory pathway is defined as an extranodal AV pathway that connects the myocardium of the atrium to the ventricle across the AV groove. Accessory pathways can be classified by their location, type of conduction (decremental or nondecremental), and whether they are capable of conducting anterogradely, retrogradely, or in both directions. Of note, accessory pathways of other types (such as atriofascicular, nodo-fascicular, nodo-ventricular, and fasciculoventricular pathways) are uncommon and are discussed only briefly in this document (Section 7). • Manifest accessory pathwaysA pathway that conducts anterogradely to cause ventricular pre-excitation pattern on the ECG. • Concealed accessory pathwayA pathway that conducts only retrogradely and does not affect the ECG pattern during sinus rhythm. • Pre-excitation patternAn ECG pattern reflecting the presence of a manifest accessory pathway connecting the atrium to the ventricle. Pre-excited ventricular activation over the accessory pathway competes with the anterograde conduction over the AV node and spreads from the accessory pathway insertion point in the ventricular myocardium. Depending on the relative contribution from ventricular activation by the normal AV nodal/His Purkinje system versus the manifest accessory pathway, a variable degree of pre-excitation, with its characteristic pattern of a short P-R interval with slurring of the initial upstroke of the QRS complex (delta wave), is observed. Pre-excitation can be intermittent or not easily appreciated for some pathways capable of anterograde conduction; this is usually associated with a low-risk pathway, but exceptions occur. • Asymptomatic pre-excitation (isolated pre-excitation)The abnormal pre-excitation ECG pattern in the absence of documented SVT or symptoms consistent with SVT. • Wolff-Parkinson-White syndromeSyndrome characterized by documented SVT or symptoms consistent with SVT in a patient with ventricular pre-excitation during sinus rhythm.Atrioventricular reentrant tachycardia (AVRT)A reentrant tachycardia, the electrical pathway of which requires an accessory pathway, the atrium, atrioventricular node (or second accessory pathway), and ventricle. • Orthodromic AVRTAn AVRT in which the reentrant impulse uses the accessory pathway in the retrograde direction from the ventricle to the atrium, and the AV node in the anterograde direction. The QRS complex is generally narrow or may be wide because of pre-existing bundle-branch block or aberrant conduction. • Antidromic AVRTAn AVRT in which the reentrant impulse uses the accessory pathway in the anterograde direction from the atrium to the ventricle, and the AV node for the retrograde direction. Occasionally, instead of the AV node, another accessory pathway can be used in the retrograde direction, which is referred to as pre-excited AVRT. The QRS complex is wide (maximally pre-excited).Permanent form of junctional reciprocating tachycardia (PJRT)A rare form of nearly incessant orthodromic AVRT involving a slowly conducting, concealed, usually posteroseptal accessory pathway.Pre-excited AFAF with ventricular pre-excitation caused by conduction over ≥1 accessory pathway(s).AF indicates atrial fibrillation; AT, atrial tachycardia; AV, atrioventricular; AVNRT, atrioventricular nodal reentrant tachycardia; AVRT, atrioventricular reentrant tachycardia; bpm, beats per minute; ECG, electrocardiogram/electrocardiographic; LA, left atrial; MAT, multifocal atrial tachycardia; PJRT, permanent form of junctional reciprocating tachycardia; PSVT, paroxysmal supraventricular tachycardia; SVT, supraventricular tachycardia; and WPW, Wolff-Parkinson-White.2.2. Epidemiology, Demographics, and Public Health ImpactThe epidemiology of SVT, including its frequency, patterns, causes, and effects, is imprecisely defined because of incomplete data and failure to discriminate among AF, atrial flutter, and other supraventricular arrhythmias. The best available evidence indicates that the prevalence of SVT in the general population is 2.29 per 1000 persons.32 When adjusted by age and sex in the US population, the incidence of paroxysmal supraventricular tachycar
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