Management – Overview: Supraventricular Arrhythmias

Atrial Fibrillation

• The acute management priorities for AF are assessing hemodynamic stability, controlling ventricular rate, considering options for rhythm control when appropriate, and initiating anticoagulation based on stroke risk.

• Rate control involves use of AV nodal blocking agents to achieve a target heart rate of <110 bpm at rest for asymptomatic patients or <80 bpm for symptomatic patients.

• Rhythm control is achieved with electrical cardioversion or pharmacological cardioversion using antiarrhythmic medications. This is indicated for patients who remain symptomatic despite adequate rate control or in hemodynamically unstable patients.

• Anticoagulation with warfarin or direct oral anticoagulants reduces the risk of stroke and systemic embolism. The decision is based on stroke risk stratification using CHA2DS2-VASc score.

Beyond the acute setting, the goals also include managing comorbidities, reducing AF burden, and preventing recurrences. Ablation procedures may be considered when antiarrhythmic medications fail to maintain sinus rhythm.

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Supraventricular Tachycardia

The goals of managing AVNRT are to acutely terminate episodes and prevent recurrences. Acute treatment focuses on restoration of normal sinus rhythm, while long-term therapy aims to modify the arrhythmia substrate. Management options include:

• Vagal maneuvers
• Pharmacologic therapy
• Electrical cardioversion
• Catheter ablation

Vagal maneuvers and/or intravenous adenosine are recommended as first-line acute treatment in hemodynamically stable patients. Synchronized electrical cardioversion is indicated for those who are unstable. Long-term management options include pharmacotherapy with antiarrhythmic medications or catheter ablation. Catheter ablation is generally preferred over lifelong drug therapy given its high efficacy and low risk. However, antiarrhythmic medications may be considered in patients with infrequent recurrences or who are not candidates for ablation.

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