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Stable Narrow Complex Tachycardia

Date Last Search Run: Apr 18, 2021
Table last updated: May 02, 2021
Data last added: Jan 26, 2021

Recommendation RECOMMENDATION FOR INTERVENTION
STRENGTH OF EVIDENCE FOR INTERVENTION   SUPPORTIVE (Green) NEUTRAL (Yellow) AGAINST (Red) NOT YET GRADED (White)
1 (strong evidence exists)  
2 (fair evidence exists)      
3 (weak evidence exists)  


Interventions

Antiarrhythmic - Class I (Na+ channel blockers)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Proportion discharged within 4 hours Patient ED-MD Scheuermeyer FX1, Andolfatto G, Christenson J, Villa-Roel C, Rowe B., A Multicenter Randomized Trial to Evaluate a Chemical-first or Electrical-first Cardioversion Strategy for Patients With Uncomplicated Acute Atrial Fibrillation. Acad Emerg Med. 2019; Sep;26(9):969-981 Medline
III Supportive (Green) Safety and Feasibility Patient Stoneman P., Gilligan P., Mahon P., Sheahan R. Chemical cardioversion of recent-onset atrial fibrillation in the emergency department using vernakalant hydrochloride achieves safe and rapid restoration of sinus rhythm and facilitates same day discharge. Ir J Med Sci 2017;186(4):903-908. Medline

Antiarrhythmic - Class III (K+ channel blockers)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Restoration of sinus rhythm Patient ED-MD Vardas PE., Kochiadakis GE. Amiodarone for the restoration of sinus rhythm in patients with atrial fibrillation. Card Electrophysiol Rev 2003; 7(3):297-299. Medline
I Neutral (Yellow) Cardioversion Patient ED-MD Stead LG., Decker WW. Evidence-based emergency medicine/systematic review abstract. Rhythm versus rate control for atrial fibrillation and flutter. Ann Emerg Med 2006; 47(5):496-498. Medline
I Neutral (Yellow) Conversion to sinus rhythm Patient ED-MD Thomas SP., Guy D., Wallace E., Crampton R., Kijvanit P., Eipper V., et al. Rapid loading of sotalol or amiodarone for management of recent onset symptomatic atrial fibrillation: a randomized, digoxin-controlled trial. Am Heart J 2004; 147(1):E3. Medline
II Supportive (Green) Conversion to Normal Sinus Rhythm, Time to conversion Process PH-Paramedic Bertini G., Conti A., Fradella G., et al. Propafenone versus amiodarone in field treatment of primary atrial tachydysrhythmias. J Emerg Med 1990; 8(1):15-20. Medline
II Supportive (Green) Conversion Patient ED-MD Stiell IG., Dickinson G., Butterfield NN., et al. Vernakalant hydrochloride: A novel atrial-selective agent for the cardioversion of recent-onset atrial fibrillation in the emergency department. Acad Emerg Med 2010; 17(11):1175-1182. Medline
II Supportive (Green) Conversion to sinus rhythm Patient ED-MD Viktorsdottir O., Henriksdottir A., Arnar DO. Ibutilide for treatment of atrial fibrillation in the emergency department. Emerg Med J 2006; 23(2):133-134. Medline

Antiarrhythmic - Class IV (Ca+ channel blockers)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Conversion to sinus rhythm Patient ED-MD Alabed S, Sabouni A, Providencia R, Atallah E, Qintar M, Chico TJ. Adenosine versus intravenous calcium channel antagonists for supraventricular tachycardia. The Cochrane database of systematic reviews 2017; 10. Medline
I Supportive (Green) Conversion of SVT Patient ED-MD Lim SH., Anantharaman V., Teo WS, Chan YH. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation 2009; 80(5):523-8. Medline
I Supportive (Green) Ventricular heart rate Patient ED-MD Schreck DM., Rivera AR., Tricarico VJ. Emergency management of atrial fibrillation and flutter: Intravenous diltiazem vs digoxin. Ann Emer Med 1997; 29:135-40. Medline
I Neutral (Yellow) Reduction in ventricular heart rate Patient ED-MD Demircan C., Cikriklar HI., Engindeniz Z., Cebicci H., Atar N., Guler V., et al. Comparison of the effectiveness of intravenous diltiazem and metoprolol in the management of rapid ventricular rate in atrial fibrillation. Emerg Med J 2005; 22(6):411-4. Medline
I Neutral (Yellow) Ventricular rate control and conversion to sinus rhythm Patient ED-MD Hassan S., Ahmad S., Kamalakannan D., et al. Conversion of Atrial Fibrillation to Sinus Rhythm During Treatment With Intravenous Esmolol or Diltiazem: A Prospective, Randomized Comparison, J of Cardio Pharm and Thera 2007; 12(3):227-31. Medline
II Supportive (Green) Conversion of SVT Patient PH-Paramedic Brady WJ. Jr., DeBehnke DJ., Wickman LL., Lindbeck G. Treatment of out-of-hospital supraventricular tachycardia: Adenosine vs verapamil. Acad Emerg Med 1996; 3(6):574-85. Medline
II Supportive (Green) Percentage of treatment failure at 4+/1 hour. Process Means KN., Gentry AE., Nguyen TT. Intravenous Continuous Infusion vs. Oral Immediate-release Diltiazem for Acute Heart Rate Control. The western journal of emergency medicine 2018;19(2):417-22. Medline
II Supportive (Green) Successful treatment Patient ED-MD Ross AL., O'Sullivan DM., Drescher MJ., Krawczynski MA. Comparison of Weight-Based Dose vs. Standard Dose Diltiazem in Patients with Atrial Fibrillation Presenting to the Emergency Department. J Emerg Med 2016;51(4):440-6. Medline
II Supportive (Green) Conversion rate Patient PH-Paramedic Smith G., McD Taylor D., Morgans A., Cameron P. Prehospital management of supraventricular tachycardia in Victoria, Australia: Epidemiology and effectiveness of therapies. Emerg Med Australas 2014; 26(4):350-355. Medline
II Supportive (Green) Cardioversion rate Patient ED-MD Vinson DR., Hoehn T., Graber DJ., Williams TM. Managing emergency department patients with recent-onset atrial fibrillation. J Emerg Med 2012; 42(2):139-148. Medline
II Supportive (Green) Functional the out-of-hospital setting. Annal of Emer Med 37: 38-45 Patient PH-Paramedic Wang HE., et al. The use of diltiazem for treating rapid atrial fibrillation in the out-of-hospital setting. Annal of Emer Med 2001; 37:38-45. Medline
II Neutral (Yellow) Conversion Patient PH-Paramedic Madsen CD., Pointer JE., Lynch TG. A comparison of adenosine and verapamil for the treatment of supraventricular tachycardia in the prehospital setting. Ann Emerg Med 1995; 25:649-655. Medline
III Supportive (Green) Conversion Patient ED-MD Innes GD., Vertesi L., Dillon EC., Metcalfe C. Effectiveness of verapamil-quinidine versus digoxin-quinidine in the emergency department treatment of paroxysmal atrial fibrillation. Ann Emerg Med 1997; 29(1):126-34. Medline

Antiarrhythmic - Class V (other mechanism)
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Converted to sinus rhythm Patient ED-MD Alabed S, Sabouni A, Providencia R, Atallah E, Qintar M, Chico TJ. Adenosine versus intravenous calcium channel antagonists for supraventricular tachycardia. The Cochrane database of systematic reviews 2017; 10. Medline
I Supportive (Green) Cardioversion success, Length of Stay Patient ED-MD Bellone A., Etteri M., Vettorello M., Bonetti C., Clerici D., Gini G., et al. Cardioversion of acute atrial fibrillation in the emergency department: a prospective randomised trial. Emerg Med J 2012; 29(3):188-91. Medline
I Supportive (Green) Time to discharge Process PH-Paramedic Honarbakhsh S., Baker V., Kirkby C., Patel K., Robinson G., Antoniou S., et al. Safety and efficacy of paramedic treatment of regular supraventricular tachycardia: a randomised controlled trial. Heart 2017;103(18):1413-8. Medline
I Supportive (Green) Conversion of SVT Patient ED-MD Lim SH., Anantharaman V., Teo WS, Chan YH. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation 2009; 80(5):523-8. Medline
II Supportive (Green) Conversion of SVT Patient PH-Paramedic Brady WJ. Jr., DeBehnke DJ., Wickman LL., Lindbeck G. Treatment of out-of-hospital supraventricular tachycardia: Adenosine vs verapamil. Acad Emerg Med 1996; 3(6):574-85. Medline
II Supportive (Green) Detection stable narrow complex tachycardia Process PH-Paramedic Lozano M., McIntosh BA., Giodano LM. Effect of Adenosine on the management of SVT by urban paramedics. Ann Emerg Med 1995; 26:691-6. Medline
II Supportive (Green) Conversion Patient PH-Paramedic Morrison LJ., Allan R., Vermeulen M., Dong SL., McCallum AL. Conversion rates for prehospital paroxysmal supraventricular tachycardia (PSVT) with the addition of adenosine: a before-and-after trial. Prehosp Emerg Care 2001; 5(4):353-9. Medline
II Neutral (Yellow) Conversion Patient PH-Paramedic Madsen CD., Pointer JE., Lynch TG. A comparison of adenosine and verapamil for the treatment of supraventricular tachycardia in the prehospital setting. Ann Emerg Med 1995; 25:649-655. Medline
II Neutral (Yellow) Rate control at 40 minutes Patient Other Milojevic K, Beltramini A, Nagash M, Muret A, Richard O, Lambert Y. Esmolol Compared with Amiodarone in the Treatment of Recent-Onset Atrial Fibrillation (RAF) An Emergency Medicine External Validity Study. J Emerg Med 2019; 56(3) 308-18. Medline
III Supportive (Green) Adenosine induced arrhythmia Process ED-MD Camaiti A., Pieralli F., Olivotto I., et al. Prospective evaluation of adenosine-induced proarrhythmia in the emergency room. Eur J Emerg Med 2001; 8(2):99-105. Medline
III Supportive (Green) Converted to sinus rhythm Patient PH-Paramedic Furlong R., Gerhardt R., Farber P., et al. Intravenous adenosine as first-line prehospital management of narrow-complex tachycardias by EMS personnel without direct physician control. Am J Emerg Med 1995; 13:383-8. Medline
III Supportive (Green) Converted to sinus rhythm Patient PH-Paramedic Gausche M., Persse D., Sugarman T., et al. Adenosine for the prehospital treatment of paroxysmal supraventricular tachycardia. Ann Emerg Med 1994; 24:183-9. Medline
III Supportive (Green) Relapse Patient PH-Paramedic Minhas R., Vogelaar G., Wang D., et al. A prehospital treat-and-release protocol for supraventricular tachycardia. CJEM 2015; 17(4):395-402. Medline
III Supportive (Green) Conversion to a sinus rhythm Patient ED-MD Podolsky SM., Varon J. Adenosine use during pregnancy. Ann Emerg Med 1991; 20(9):1027-8. Medline
III Supportive (Green) Conversion to normal sinus rhythm. Patient PH-Paramedic Wittwer LK., Muhr MD. Adenosine for the treatment of PSVT in the prehospital arena: Efficacy of an initial 6 mg dosing regimen. Prehosp Disaster Med 1997; 12(3):237-239. Medline
III Opposes (Red) Death Patient PH-Paramedic Haynes BE. Two deaths after prehospital use of adenosine. J Emerg Med 2001; 21(2):151-4. Medline

Beta Blockers
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Reduction in ventricular heart rate Patient ED-MD Demircan C., Cikriklar HI., Engindeniz Z., Cebicci H., Atar N., Guler V., et al. Comparison of the effectiveness of intravenous diltiazem and metoprolol in the management of rapid ventricular rate in atrial fibrillation. Emerg Med J 2005; 22(6):411-4. Medline
I Neutral (Yellow) Cardioversion Patient ED-MD Stead LG., Decker WW. Evidence-based emergency medicine/systematic review abstract. Rhythm versus rate control for atrial fibrillation and flutter. Ann Emerg Med 2006; 47(5):496-498. Medline
II Supportive (Green) Rate control at 40 minutes Patient Other Milojevic K, Beltramini A, Nagash M, Muret A, Richard O, Lambert Y. Esmolol Compared with Amiodarone in the Treatment of Recent-Onset Atrial Fibrillation (RAF) An Emergency Medicine External Validity Study. J Emerg Med 2019; 56(3) 308-18. Medline
II Neutral (Yellow) Predictors of choice of rate control therapy Process Hines MC., Reed BN., Ivaturi V., Bontempo LJ., Bond MC., Hayes BD. Diltiazem versus metoprolol for rate control in atrial fibrillation with rapid ventricular response in the emergency department. Am J Health Syst Pharm 2016;73(24):2068-76. Medline
X Not Yet Graded (White) - Hargrove KL, Robinson EE, Lusk KA, Hughes DW, Neff LA, Fowler AL. Comparison of sustained rate control in atrial fibrillation with rapid ventricular rate: Metoprolol vs. Diltiazem. Am J Emerg Med 2021; 40:15-9. Medline

Carotid Massage
Level Direction Primary Outcome Patient/Process Setting Reference
I Neutral (Yellow) Conversion Patient In-Patient Lim S., Anantharaman V., Teo W., et al. Comparison of treatment of supraventricular tachycardia by valsalva maneuver and carotid sinus massage. Annals of Emerg Med 1998; 31:30-35. Medline

Electrical Cardioversion
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Cardioversion success, Length of Stay Patient ED-MD Bellone A., Etteri M., Vettorello M., Bonetti C., Clerici D., Gini G., et al. Cardioversion of acute atrial fibrillation in the emergency department: a prospective randomised trial. Emerg Med J 2012; 29(3):188-91. Medline
I Supportive (Green) Discharge from ED within 4 hours. Patient ED-MD Scheuermeyer FX1, Andolfatto G, Christenson J, Villa-Roel C, Rowe B., A Multicenter Randomized Trial to Evaluate a Chemical-first or Electrical-first Cardioversion Strategy for Patients With Uncomplicated Acute Atrial Fibrillation. Acad Emerg Med. 2019; Sep;26(9):969-981 Medline
II Supportive (Green) Conversion Patient ED-MD Cohn BG., Keim SM., Yealy DM. Is emergency department cardioversion of recent-onset atrial fibrillation safe and effective? J Emerg Med 2013; 45(1):117-27. Medline
II Supportive (Green) Cardioversion success Patient ED-MD Dankner R., Shahar A., Novikov I., Agmon U., Ziv A., Hod H. Treatment of stable atrial fibrillation in the emergency department: A population-based comparison of electrical direct-current versus pharmacological cardioversion or conservative management. Cardiology 2009; 112(4):270-8. Medline
II Supportive (Green) Cardioversion rate Patient ED-MD Vinson DR., Hoehn T., Graber DJ., Williams TM. Managing emergency department patients with recent-onset atrial fibrillation. J Emerg Med 2012; 42(2):139-148. Medline
II Neutral (Yellow) Cardiac rhythm conversion Patient ED-MD Gallagher MM., Yap YG., Padula M., Ward DE., Rowland E., Camm AJ. Arrhythmic complications of electrical cardioversion: relationship to shock energy. Int J Cardiol 2008; 123(3):307-12. Medline
III Supportive (Green) Rhythm conversion, complications Patient ED-MD Burton JH., Vinson DR., Drummond K., Strout TD., Thode HC., McInturff JJ. Electrical cardioversion of emergency department patients with atrial fibrillation. Ann Emerg Med 2004; 44(1):20-30. Medline
X Not Yet Graded (White) - Fried AM, Strout TD, Perron AD. Electrical cardioversion for atrial fibrillation in the emergency department: A large single-center experience. Am J Emerg Med 2021; 42:115-20. Medline

Fluid Bolus
Level Direction Primary Outcome Patient/Process Setting Reference

Modified Valsalva
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Conversion Patient Appelboam A., Reuben A., Mann C., et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. The Lancet 2015; 386(10005):1747–53. Medline
I Supportive (Green) Success rate of achieving sinus rhythm and discharge from ED Process Çorbacıoğlu ŞK., Akıncı E., Çevik Y., Aytar H., Öncül MV., Akkan S., et al. Comparing the success rates of standard and modified Valsalva maneuvers to terminate PSVT: A randomized controlled trial. Am J Emerg Med 2017;35(11):1662-5. Medline
III Neutral (Yellow) Valsalva maneuver success Patient ED-MD Walker S, Cutting P. Impact of a modified Valsalva in termination PSVT. EMJ 2010; 27:291-7. Medline

Treat and Release-SVT
Level Direction Primary Outcome Patient/Process Setting Reference
III Supportive (Green) Relapse Patient PH-Paramedic Minhas R., Vogelaar G., Wang D., et al. A prehospital treat-and-release protocol for supraventricular tachycardia. CJEM 2015; 17(4):395-402. Medline

Vagal Maneuvers
Level Direction Primary Outcome Patient/Process Setting Reference
III Neutral (Yellow) Relapse Patient PH-Paramedic Minhas R., Vogelaar G., Wang D., et al. A prehospital treat-and-release protocol for supraventricular tachycardia. CJEM 2015; 17(4):395-402. Medline

Valsalva maneuver
Level Direction Primary Outcome Patient/Process Setting Reference
I Supportive (Green) Conversion Patient Appelboam A., Reuben A., Mann C., et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. The Lancet 2015; 386(10005):1747–53. Medline
I Neutral (Yellow) Success rate of achieving sinus rhythm and discharge from ED Process Çorbacıoğlu ŞK., Akıncı E., Çevik Y., Aytar H., Öncül MV., Akkan S., et al. Comparing the success rates of standard and modified Valsalva maneuvers to terminate PSVT: A randomized controlled trial. Am J Emerg Med 2017;35(11):1662-5. Medline
I Neutral (Yellow) Termination of SVT Patient ED-MD Lim S., Anantharaman V., Teo W., et al. Comparison of treatment of supraventricular tachycardia by valsalva maneuver and carotid sinus massage. Annals of Emerg Med 1998; 31:30-35. Medline
I Neutral (Yellow) Termination of SVT Patient ED-MD Smith GD., Fry MM., Taylor D., et al. Effectiveness of the Valsalva Manoeuvre for reversion of supraventricular tachycardia. Cochrane Database Syst Rev 2015; 2:CD009502. (Review) PMID: 25692498. Medline
II Neutral (Yellow) Conversion rate Patient PH-Paramedic Smith G., McD Taylor D., Morgans A., Cameron P. Prehospital management of supraventricular tachycardia in Victoria, Australia: Epidemiology and effectiveness of therapies. Emerg Med Australas 2014; 26(4):350-355. Medline
III Supportive (Green) Predictive value Process ED-MD Smith G., Taylor DM., Morgans A., Cameron P. Prehospital synchronized electrical cardioversion of a poorly perfused SVT patient by paramedics. Prehosp Disaster Med 2013; 28(3):301-304. Medline
III Neutral (Yellow) Conversion Patient ED-MD Ornato J., Hallagan L., Reese W., et al. Treatment of paroxysmal supraventricular tachycardia in the emergency department by clinical decision analysis. Am J Emerg Med 1988; 6:555-60. Medline
III Neutral (Yellow) Conversion Patient PH-Paramedic Smith G., Morgans A., Boyle M. Use of the Valsalva manoeuvre in the prehospital setting: a review of the literature. EMJ 2009; 26:8-10. Medline


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