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Sixteen years after the last ESC guidelines covering the management of supraventricular tachycardia (SVT) were published, the new 2019 ESC Guidelines for the management of patients with supraventricular tachycardia1 have been eagerly awaited. Guideline Review Coordinators, Professor Christian Sticherling (University Hospital Basel, Basel, Switzerland) and Doctor Tom De Potter (OLV Hospital, Aalst, Belgium), highlight what they consider to be the main changes and discuss what these changes mean for clinical practice.
Prof. Sticherling explains why the ESC Guidelines on SVT are different to other ESC management guidelines. “Since the 2003 ESC Guidelines, there has been a dichotomous development in the invasive management of arrhythmias, with traditional paroxysmal SVT on the one hand and atrial fibrillation (AF) on the other. Most randomised clinical trials have been conducted in AF as it is the most common supraventricular arrhythmia, with only a few trials in paroxysmal SVTs, which are rarer and mostly not life-threatening. This means that, compared with many of the other ESC guidelines, the scientific evidence supporting recommendations in the SVT management guidelines is less clear-cut.
By far the biggest change in management concerns drug treatment, says Dr. De Potter. “In 2003, the go-to treatment for arrhythmias was drugs. Since then, it has become clear that while drugs still have a place in the acute setting, they are generally not appropriate for long-term use. In fact, we now know that amiodarone and digoxin are potentially harmful for chronic treatment. A large number of the drugs cited in the previous guidelines are not featured in this version.”
Today, catheter ablation—which was emerging from its infancy in 2003—has a much more prominent place in the treatment of SVT.
“Being associated with only a very small risk of complications, ablation should be offered as a first-line treatment option to most patients without contraindications,” says Dr. De Potter. This recommendation is probably in keeping with current practice throughout Europe.
Highlighting what he sees as other major changes, Prof. Sticherling touches on the subject of asymptomatic pre-excitation. One in five patients with this condition will develop an arrhythmia related to their accessory pathway in follow-up. In the new guidelines, asymptomatic pre-excitation has a dedicated algorithm for its screening and management. Non-invasive screening can be used for risk stratification but it has only modest predictive ability; invasive electrophysiology evaluation and ablation is recommended for those with high-risk occupations.
“Last but not least,” continues Prof. Sticherling, “the new guidelines have separate sections considering management approaches for subgroups of patients with particular needs—such as adults with congenital heart disease, paediatric patients and patients who are pregnant—and they discuss SVT in the context of sport and driving restrictions.” Dr. De Potter expands on the issue of SVT in pregnancy, which carries a higher risk of death. “If treatment is considered necessary because of maternal or child safety, drugs are not always the most suitable choice, particularly during the first trimester. Instead, catheter ablation should be considered at an expert centre with the appropriate facilities and technology.” Alternatively, beta-1 selective blockers (except atenolol) or verapamil, in order of preference, are recommended for the prevention of SVT in patients without Wolff-Parkinson-White syndrome. Ideally, catheter ablation should be considered for patients with a history of symptomatic recurrent SVT who are planning to become pregnant at some point in the future.
Both Review Coordinators recognise the difficulty of developing guidelines in an area that has few large-scale trials and that has a wide audience, given that most cardiologists will be faced with SVT. “A lot of time and energy has gone into shaping the content to strike the right balance between a textbook overview and a summary of the available evidence,” says Dr. De Potter. Prof. Sticherling agrees, “The current guidelines give a comprehensive overview of the area and provide clinicians in all areas of cardiology with an important and long-overdue reference document for managing SVT.”
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1. 2019 ESC Guidelines for the management of patients with supraventricular tachycardia. Eur Heart J 2019. doi/10.1093/eurheartj/ehz467Replay the video and slides on ESC 365: www.escardio.org/365
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