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Dr Demos Katritsis and his writing group have produced an important new guidelines document on the management of all types of supraventricular tachycardias (SVTs). The one exception is atrial fibrillation (AF), which is covered in the 2016 European Society of Cardiology (ESC) AF guidelines. This document is a complete rewrite of the 2003 SVT guidelines, which were published as a joint document with the American Heart Association and the American College of Cardiology. In this brief article, I will highlight the most important features of the new 2019 ESC SVT Guidelines. The first important change in the 2019 ESC SVT guideline, when compared with the prior guideline published 16 years earlier is that the Class and level of recommendations supporting catheter ablation for chronic treatment of all types of SVTs have been increased. This shift reflects the vast literature, and large and consistent worldwide experience supporting the curative role of catheter ablation for most types of SVT. Catheter ablation is now provided with a Class 1 level of evidence (LOE) A or B recommendation for nearly all SVTs. The most notable exceptions to this rule are inappropriate sinus tachycardia and multifocal atrial tachycardia, for which catheter ablation plays little to no role in management. Another exception is SVTs in patients with congenital heart disease, where catheter ablation in experienced centres is provided a 2A, LOE C recommendation. Another important change reflects the role of pharmacologic therapy in SVT management. The document has downgraded the Class and LOE of recommendations for pharmacologic therapy of most types of SVTs. This shift reflects the remarkable paucity of data from clinical trials demonstrating the safety and efficacy of most antiarrhythmic agents, including beta-blockers, calcium channel blockers, digoxin, and also Class 1 and 3 antiarrhythmic agents. Oral disopyramide, procainamide, quinidine, and sotalol are not included in the document. The only recognized role of amiodarone is for acute management of wide complex tachycardia (Class 2b, LOE B), focal atrial tachycardia (Class 2b, LOE C), macro-reentrant atrial arrhythmias (Class 2b, LOE C), and antidromic atrioventricular reentrant tachycardia (Class 2b, LOE B). And the only recognized role for amiodarone for chronic SVT management is for treatment of patients with macro-reentrant atrial tachycardia (Class 2b, LOE C) and also for treatment of SVT in congenital heart disease patients when catheter ablation is not possible or successful (Class 2b, LOE C). Amiodarone is not listed as a chronic therapy for atrioventricular nodal reentrant tachycardia and receives a Class 2, LOE B recommendation for pre-excited AF. A third important update in this new SVT guideline concerns the management of patients with asymptomatic pre-excitation. Since publication of the 2003 guidelines, there have been many studies which have provided new data to help guide evaluation and management of patients with asymptomatic pre-excitation. Based on these studies, it is now recommended that asymptomatic patients with pre-excitation who have high-risk occupations or are competitive athletes should undergo an electrophysiology study (EPS) with isoproterenol infusion for risk stratification (Class 1<LOE B). If a high-risk accessory pathway (AP) is identified, catheter ablation is recommended (Class 1, LOE B). For all patients, performing a risk stratifying EPS is given a Class 2a, LOE B recommendation. Non-invasive risk stratification is provided a 2b, LOE B recommendation. And if a non-low-risk AP is identified an EPS is recommended. Another important new recommendation is that catheter ablation is recommended in a patient with reduced left ventricular function and asymptomatic pre-excitation that may cause ventricular dyssynchrony (e.g. a right-sided AP). Finally, this document also allows for catheter ablation of an AP in a patient with asymptomatic preexcitation and an EPS demonstrating low-risk properties (Class 2B, LOE C), based on the operator’s experience and the patient’s preferences. A final important component of the new 2019 ESC SVT Guidelines concerns anticoagulation recommendations in patients with atrial flutter. The document provides a Class1 LOE B recommendation for anticoagulation in patients with both AF and atrial flutter based on current AF guidelines. But the document also states that patients with atrial flutter without AF should be considered for anticoagulation but the

The 2019 ESC Guidelines for the Management of Patients with Supraventricular Tachycardia