Version July 2025
| Arrhythmia | Treatment options | Contraindicated therapies |
| Orthodromic AV reentrant tachycardia | ||
| Acute termination* | Unstable patients: Synchronized cardioversion Stable patients:
| |
| Chronic prevention¶ | First line: Catheter ablation of the accessory pathway Second line: Oral flecainide or propafenone in the absence of structural or ischemic heart disease Third line: Oral IA antiarrhythmic agent or oral amiodarone | |
| Antidromic AV reentrant tachycardia | ||
| Acute termination* | Unstable patients: Synchronized cardioversion Stable patients (if CERTAIN of the diagnosis): Same progression of therapies as acute termination of orthodromic AVRTΔ Stable patients (if NOT certain of the diagnosis): IV procainamide, synchronized cardioversion if procainamide is ineffective or not availableΔ | Adenosine, verapamil, diltiazem, beta blockers, digoxin should all be avoided if not certain of diagnosis |
| Chronic prevention¶ | First line: Catheter ablation of the accessory pathway Second line: Oral flecainide or propafenone in the absence of structural or ischemic heart disease Other therapies: Oral IA antiarrhythmic agent or oral amiodarone | Digoxin Beta blockers Verapamil, diltiazem |
| Pre-excited atrial fibrillation | ||
| Acute termination* | Unstable patients: Synchronized cardioversion Stable patients:
| Amiodarone Digoxin Beta blockers Adenosine Verapamil, diltiazem |
| Chronic prevention¶ | First line: Catheter ablation of the accessory pathway Second line: Oral flecainide or propafenone in the absence of structural or ischemic heart disease Third line: Oral IA antiarrhythmic agent or oral amiodarone | Oral digoxin |
AVRT: atrioventricular reciprocating tachycardia; IV: intravenous; class IC: flecainide, propafenone; class IA: quinidine, procainamide, disopyramide.
* Cardioversion is indicated if hemodynamically unstable or drugs are ineffective.
¶ Ablation of the accessory pathway is generally preferred to cure the arrhythmia.
Δ Procainamide is the intravenous drug of choice for acute termination of suspected antidromic AVRT. If the tachycardia is definitely known to be antidromic AVRT, and it has been verified that the AV node (rather than a second accessory pathway) is acting as the retrograde limb of the circuit, one could consider treatment with an agent such as adenosine similar to therapy for orthodromic AVRT, but it is rare to have all of the necessary data in the acute setting to justify use of AV nodal blocking agents.
