Supraventricular tachycardia

Last updated: March 24, 2022

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Supraventricular tachycardias (SVTs) are a group of tachyarrhythmias arising from abnormalities in pacemaker activity and/or conduction involving myocytes of the atria and/or AV node. Types of SVT include atrioventricular nodal reentrant tachycardia (AVNRT; approx. two-thirds of cases), atrioventricular reciprocating (or reentrant) tachycardia (AVRT), focal atrial tachycardia (FAT), multifocal atrial tachycardia (MAT), and junctional tachycardia. AVNRT and AVRT are caused by abnormal conduction circuits that form an unending loop of conduction referred to as reentry. These reentry circuits can occur between parallel pathways within the AV node (as in AVNRT) or between the AV node and an accessory pathway of atrioventricular conduction (as in AVRT). Atrial tachycardias (FAT and MAT) and junctional tachycardias are usually the result of abnormal or ectopic pacemaker activity and do not involve reentry. The most common congenital accessory pathway (bundle of Kent) is seen in Wolff-Parkinson-White (WPW) syndrome and can cause ventricular preexcitation, in which supraventricular impulses bypass the AV node and are abnormally conducted to the ventricles, leading to a characteristic preexcitation pattern on ECG and a specific subset of preexcited tachyarrhythmias. SVTs have similar clinical features (typically paroxysms of tachycardia with dizziness, dyspnea, chest pain, or syncope) that may be self-limiting or progress to hemodynamic instability and sudden cardiac death. Common diagnostic steps include obtaining the patient's history and a 12-lead ECG to identify the type of SVT. The paroxysmal nature of SVTs means that continuous recording with a Holter monitor is often needed to confirm the diagnosis; in some cases, invasive electrophysiological studies (EP studies) may also be indicated. Management of SVT should be tailored to the patient. Hemodynamically unstable patients should undergo emergency cardioversion, while patients with acute SVT episodes that are hemodynamically stable may benefit from vagal maneuvers and/or antiarrhythmic medication (typically intravenous), depending on the underlying rhythm (see “Management of tachycardia”). Long-term management may involve antiarrhythmic medication or curative catheter ablation.

While atrial fibrillation and atrial flutter are types of supraventricular tachycardia, they are usually considered separately (see “Atrial fibrillation”).



Epidemiology [2]

Clinical features [2][8]

For all patients with a new SVT, a 12-lead ECG, basic laboratory studies, and a TTE should be obtained. Further testing depends on patient risk factors but may include exercise tolerance testing or myocardial ischemia testing. An EP study can be used for simultaneous diagnosis and treatment. [8]

Initial diagnostics [8]

Additional diagnostics [8]

Differential diagnoses

Although differentiating between types of SVT can be challenging and may require EP studies to confirm the diagnosis, some ECG features may help to differentiate diagnoses.

Patients with SVT symptoms are frequently misdiagnosed with anxiety or panic disorders. Paroxysmal tachycardia should be ruled out before making a psychiatric diagnosis to avoid anchoring bias.

For clinically oriented algorithms of acute management of tachycardia see “Management of unstable tachycardia with a pulse” and “Management of undifferentiated SVT”. This section provides an overview of the management of SVT. The dedicated sections of this article (e.g., AVNRT) contain more specific information.

General principles

Vagal maneuvers

Valsalva maneuver

Modified Valsalva maneuver [11]

  • Patient sits in a semirecumbent position
  • Blows into a 10 mL syringe for 15 seconds (moving the plunger up achieves a strain of ∼ 40 mm Hg) [12]
  • Afterwards the patient is laid supine and the legs are passively elevated to 45° for 15 seconds.
  • Return to the semirecumbent position for 45 seconds before reassessing rhythm

Carotid sinus massage [13]

Diving reflex

  • Traditionally involves immersing the head in cold water, which is uncomfortable for most patients
  • Can be limited to applying a bag of ice water to the face (particularly the forehead and nasal area) for ∼ 10 seconds [15]

Do not simultaneously apply bilateral carotid artery pressure because this can impede cerebral blood flow.

Medical therapy

See “Management of undifferentiated SVT” for a clinically oriented algorithmic approach and the dedicated sections of this article (e.g., “Treatment of AVNRT”) for more specific information.

Catheter ablation

  • Description
    • Radiofrequency or cryothermal energy is applied via a cardiac catheter to eliminate aberrant pathways or impulses from arrhythmogenic foci.
    • Usually performed in conjunction with an EP study
  • Indications [2]
    • Curative therapy in AVNRT, AVRT with concealed pathway, or drug-refractory AT
    • Symptomatic patients who want to avoid long-term drug therapy (especially younger patients)
    • Asymptomatic patients with special lifestyle considerations (e.g., pilots)


  • A tachyarrhythmia caused by a dysfunctional AV node that contains two electrical pathways, which form a reentry circuit


  • The AV node contains two electrical pathways, one fast and one slow → the electrical impulse circles around the AV node within both pathways → a continuous circuit conducts impulses to the ventricles → tachycardia
  • Approx. 90% of cases are due to anterograde conduction across the slow-conducting pathway and retrograde conduction in the fast pathway (although the reverse is possible).

ECG findings in AVNRT [16][17]

Treatment of AVNRT

Acute management

Long-term management



  • Accessory pathways may be manifest or concealed. [8][21]
    • Manifest pathways
      • Can conduct in both anterograde (atrium to ventricle) and retrograde (ventricle to atrium) directions
      • Anterograde conduction is more common and leads to preexcitation seen on the ECG in sinus rhythm. [21]
    • Concealed pathways
      • Can conduct only in a retrograde direction
      • Not visible on ECG in sinus rhythm
  • There are two types of atrioventricular reciprocating tachycardia; the direction of the impulses help distinguish between them.

Do not confuse atrioventricular reentrant (or reciprocating) tachycardia (AVRT) with atrioventricular nodal reentrant tachycardia (AVNRT)! AVRT is caused by an accessory pathway, whereas in AVNRT there are two functional pathways within the AV node.

ECG findings

ECG findings in AVRT [8][25][26]
Orthodromic AVRT
Antidromic AVRT

Treatment of AVRT

Acute episodes

Long-term management [2]




ECG findings in WPW

Treatment of WPW

Acute episodes

AV nodal blocking agents and vagal maneuvers are contraindicated in patients with ventricular preexcitation and the following underlying tachyarrhythmias: Afib, atrial flutter, FAT, and MAT.

Long-term management [2][32]

Management of WPW pattern and WPW syndrome depends on underlying risk factors and patient preference.

Risk stratification in WPW syndrome [36]

Risk stratification is determined by a cardiologist based on clinical, ECG, and electrophysiological parameters.

High-risk patients

Catheter ablation of the accessory pathway should be offered to all patients. [2]

Low-risk patients [2]


Etiology [38]

Pathophysiology [39][40]

ECG findings [2][42]

An isoelectric baseline between P waves can help distinguish focal AT from atrial flutter. [43]

Treatment [2]

Acute episodes

Episodes of FAT are most commonly self-limiting and asymptomatic, in which case they do not require treatment.

Avoid AV nodal blockers in patients with preexcited FAT (e.g., due to WPW) because they can trigger ventricular arrhythmias.

Long-term management


  • An irregular SVT featuring ≥ 3 morphologies of P waves [2]

Etiology [47][48]

Pathophysiology [50]

ECG findings [47]

Do not confuse MAT with atrial fibrillation. In Afib, there are no distinct or organized P waves, whereas in MAT there are distinct P waves with varying morphologies.

Unlike in atrial flutter, in MAT there are distinct isoelectric intervals between P waves.

Treatment of multifocal atrial tachycardia [2][8][51]

Treatment of MAT is challenging and specialists should be involved early. Patients often have severe underlying conditions and rhythm control and electrical cardioversion are not effective. For clinically-oriented management algorithms for patients with tachycardia, see “Management of tachycardia”.

Avoid AV nodal blockers in patients with preexcited MAT (e.g., due to WPW) because of the risk of ventricular arrhythmias.

Avoid electrical cardioversion and antiarrhythmic drugs (e.g., procainamide, lidocaine, phenytoin), as they are not effective in treating MAT. [2][51]


Etiology [2]

Pathophysiology [2][8]

ECG findings [2][55]

While the rate varies between paroxysmal junctional tachycardia and accelerated AV junctional rhythm, the ECG appearance is otherwise similar.

Treatment of junctional tachycardia [2]

These recommendations are for confirmed junctional tachycardia. For clinically-oriented management algorithms for patients with tachycardia, see “Management of tachycardia.”

  1. Brugada J, Katritsis DG, Arbelo E, et al. 2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J. 2019; 41 (5): p.655-720. doi: 10.1093/eurheartj/ehz467 . | Open in Read by QxMD
  2. Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia. Circulation. 2016; 133 (14): p.e506–e574. doi: 10.1161/cir.0000000000000311 . | Open in Read by QxMD
  3. Papadopoulos CH, Oikonomidis D, Lazaris E, Nihoyannopoulos P. Echocardiography and cardiac arrhythmias. Hellenic J Cardiol. 2018; 59 (3): p.140-149. doi: 10.1016/j.hjc.2017.11.017 . | Open in Read by QxMD
  4. Wang PJ, Estes NAM. Supraventricular Tachycardia. Circulation. 2002; 106 (25). doi: 10.1161/01.cir.0000044341.43780.c7 . | Open in Read by QxMD
  5. 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. Lancet. 2015; 386 (10005): p.1747-1753. doi: 10.1016/s0140-6736(15)61485-4 . | Open in Read by QxMD
  6. Smith G, Boyle MJ. The 10 mL syringe is useful in generating the recommended standard of 40 mmHg intrathoracic pressure for the Valsalva manoeuvre. Emerg Med Australas. 2009; 21 (6): p.449-454. doi: 10.1111/j.1742-6723.2009.01228.x . | Open in Read by QxMD
  7. Marshall SA, Ruedy J. On Call Principles and Protocols E-Book. Elsevier Health Sciences ; 2010
  8. Vincent J-L, Abraham E, Kochanek P, Moore FA, Fink MP. Textbook of Critical Care E-Book. Elsevier Health Sciences ; 2011
  9. Fleisher GR, Ludwig S. Textbook of Pediatric Emergency Medicine . Lippincott Williams & Wilkins ; 2010
  10. Hare M, Ramlakhan S. Handstands: a treatment for supraventricular tachycardia?. Arch Dis Child. 2014; 100 (1): p.54-56. doi: 10.1136/archdischild-2014-306949 . | Open in Read by QxMD
  11. Bohnen M, Stevenson WG, Tedrow UB, et al. Incidence and predictors of major complications from contemporary catheter ablation to treat cardiac arrhythmias. Heart Rhythm. 2011; 8 (11): p.1661-1666. doi: 10.1016/j.hrthm.2011.05.017 . | Open in Read by QxMD
  12. Gupta A, Perera T, Ganesan A, et al. Complications of Catheter Ablation of Atrial Fibrillation. Circulation: Arrhythmia and Electrophysiology. 2013; 6 (6): p.1082-1088. doi: 10.1161/circep.113.000768 . | Open in Read by QxMD
  13. Desforges JF, Kastor JA. Multifocal Atrial Tachycardia. N Engl J Med. 1990; 322 (24): p.1713-1717. doi: 10.1056/nejm199006143222405 . | Open in Read by QxMD
  14. Wang K. Multifocal Atrial Tachycardia. Arch Intern Med. 1977; 137 (2): p.161. doi: 10.1001/archinte.1977.03630140017007 . | Open in Read by QxMD
  15. Bittar G, Friedman HS. The Arrhythmogenicity of Theophylline. Chest. 1991; 99 (6): p.1415-1420. doi: 10.1378/chest.99.6.1415 . | Open in Read by QxMD
  16. Santos-Ocampo CD, Sadaniantz A, Elion JL, Garber CE, Malone LL, Parisi AF. Echocardiographic assessment of the cardiac anatomy in patients with multifocal atrial tachycardia: a comparison with atrial fibrillation.. Am J Med Sci. 1994; 307 (4): p.264-8. doi: 10.1097/00000441-199404000-00004 . | Open in Read by QxMD
  17. Kastor JA. Multifocal Atrial Tachycardia. Card Electrophysiol Rev. 1997; 1 (1/2): p.71-75. doi: 10.1023/a:1009919619830 . | Open in Read by QxMD
  18. Iseri LT, Fairshter RD, Hardemann JL, Brodsky MA. Magnesium and potassium therapy in multifocal atrial tachycardia. Am Heart J. 1985; 110 (4): p.789-794. doi: 10.1016/0002-8703(85)90458-2 . | Open in Read by QxMD
  19. Neumar RW, Otto CW, Link MS, et al. Part 8: Adult Advanced Cardiovascular Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 122 (18_suppl_3): p.S729-S767. doi: 10.1161/circulationaha.110.970988 . | Open in Read by QxMD
  20. Stouffer G, Runge MS, Patterson C. Netter's Cardiology E-Book. Elsevier Health Sciences ; 2010
  21. Podrid P, MD P, Malhotra R, et al.. Podrid's Real-World ECGs: Volume 4A, Arrhythmias [Core Cases]. Cardiotext Publishing ; 2014
  22. Munro J, Shen W-K, Srivathsan K. Pre-excited tachycardia: Atrial tachycardia with a bystander left lateral accessory pathway. HeartRhythm Case Reports. 2016; 2 (4): p.334-338. doi: 10.1016/j.hrcr.2016.03.012 . | Open in Read by QxMD
  23. H Heidbüchel. How to ablate typical 'slow/fast' AV nodal reentry tachycardia. Europace. 2000; 2 (1): p.15-19. doi: 10.1053/eupc.1999.0070 . | Open in Read by QxMD
  24. Alboni P, Tomasi C, Menozzi C, et al. Efficacy and safety of out-of-hospital self-administered single-dose oral drug treatment in the management of infrequent, well-tolerated paroxysmal supraventricular tachycardia. J Am Coll Cardiol. 2001; 37 (2): p.548-553. doi: 10.1016/s0735-1097(00)01128-1 . | Open in Read by QxMD
  25. Hanna Deschamps E, Hanna EB. Atrioventricular Accessory Pathways: Mechanisms, Electrocardiograms, and Associated Arrhythmias. South Med J. 2016; 109 (10): p.670-676. doi: 10.14423/smj.0000000000000538 . | Open in Read by QxMD
  26. Ali R, Tahir A, Nadeem M, Shakhatreh MI, Faulknier B. Antidromic Atrioventricular Reentry Tachycardia with Wolff Parkinson White Syndrome: A Rare Beast. Cureus. 2018 . doi: 10.7759/cureus.2642 . | Open in Read by QxMD
  27. Kylat RI, Samson RA. Permanent junctional reciprocating tachycardia in infants and Children. J Arrhythm. 2019; 35 (3): p.494-498. doi: 10.1002/joa3.12193 . | Open in Read by QxMD
  28. Rao BNVR. Clinical Examinations in Cardiology - E-Book. Elsevier Health Sciences ; 2007
  29. Marini JJ, Wheeler AP. Critical Care Medicine. Lippincott Williams & Wilkins ; 2010
  30. Jayasinghe R. ECG workbook - E-Book. Elsevier Health Sciences ; 2012
  31. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  32. Roberts-Thomson KC, Kistler PM, Kalman JM. Focal atrial tachycardia I: clinical features, diagnosis, mechanisms, and anatomic location.. Pacing Clin Electrophysiol. 2006; 29 (6): p.643-52. doi: 10.1111/j.1540-8159.2006.00413.x . | Open in Read by QxMD
  33. Kistler PM, Roberts-Thomson KC, Haqqani HM, et al. P-Wave Morphology in Focal Atrial Tachycardia. J Am Coll Cardiol. 2006; 48 (5): p.1010-1017. doi: 10.1016/j.jacc.2006.03.058 . | Open in Read by QxMD
  34. Chen SA, Chiang CE, Yang CJ, et al. Sustained atrial tachycardia in adult patients. Electrophysiological characteristics, pharmacological response, possible mechanisms, and effects of radiofrequency ablation.. Circulation. 1994; 90 (3): p.1262-1278. doi: 10.1161/01.cir.90.3.1262 . | Open in Read by QxMD
  35. Buttà C, Tuttolomondo A, Giarrusso L, Pinto A. Electrocardiographic Diagnosis of Atrial Tachycardia: Classification, P-Wave Morphology, and Differential Diagnosis with Other Supraventricular Tachycardias. Annals of Noninvasive Electrocardiology. 2014; 20 (4): p.314-327. doi: 10.1111/anec.12246 . | Open in Read by QxMD
  36. Blomström-Lundqvist C, Scheinman MM, Aliot EM, et al. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary. a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society.. J Am Coll Cardiol. 2003; 42 (8): p.1493-531. doi: 10.1016/j.jacc.2003.08.013 . | Open in Read by QxMD
  37. Medi C, Kalman JM, Haqqani H, et al. Tachycardia-mediated cardiomyopathy secondary to focal atrial tachycardia: long-term outcome after catheter ablation.. J Am Coll Cardiol. 2009; 53 (19): p.1791-7. doi: 10.1016/j.jacc.2009.02.014 . | Open in Read by QxMD
  38. Walters TE, Kistler PM, Kalman JM. Radiofrequency Ablation for Atrial Tachycardia and Atrial Flutter. Heart, Lung and Circulation. 2012; 21 (6-7): p.386-394. doi: 10.1016/j.hlc.2012.02.001 . | Open in Read by QxMD
  39. Roberts-Thomson KC, Kistler PM, Kalman JM. Focal atrial tachycardia II: management.. Pacing Clin Electrophysiol. 2006; 29 (7): p.769-78. doi: 10.1111/j.1540-8159.2006.00433.x . | Open in Read by QxMD
  40. Chrispin J, Calkins H. Accessory pathways-related tachycardias: Wolff–Parkinson–White syndrome and atrioventricular reentrant tachycardias. Oxford University Press ; 2018 : p. 2085-2091
  41. Fleisher LA, Roizen MF, Roizen J. Essence of Anesthesia Practice E-Book. Elsevier Health Sciences ; 2017
  42. Surawicz B, Knilans T. Chou's Electrocardiography in Clinical Practice E-Book. Elsevier Health Sciences ; 2008
  43. Crawford MH, DiMarco JP, Paulus WJ. Cardiology E-Book. Elsevier Health Sciences ; 2009
  44. Sidhu J, Roberts R. Genetic basis and pathogenesis of familial WPW syndrome.. Indian Pacing Electrophysiol J. 2003; 3 (4): p.197-201.
  45. Zipes DP. Braunwald's Heart Disease. Mosby ; 2018
  46. Bergsma D. Birth Defects Compendium. Springer ; 2016
  47. Hollenberg SM, Heitner S. Cardiology in Family Practice. Springer Science & Business Media ; 2011
  48. Atlee JL. Complications in Anesthesia. Elsevier Health Sciences ; 2007
  49. Azeem T, Vassallo M, Samani NJ. Rapid Review of ECG Interpretation. CRC Press ; 2005
  50. Saksena S, Camm AJ. Electrophysiological Disorders of the Heart E-Book. Elsevier Health Sciences ; 2011
  51. Brugada J, Keegan R. Asymptomatic Ventricular Pre-excitation: Between Sudden Cardiac Death and Catheter Ablation.. Arrhythm Electrophysiol Rev. 2018; 7 (1): p.32-38. doi: 10.15420/aer.2017.51.2 . | Open in Read by QxMD
  52. Surawicz, B; C. Pratap Reddy, C; Prystowsky, EN. Tachycardia. Springer Science & Business Media ; 2012
  53. Adelmann GA. Cardiology Essentials in Clinical Practice. Springer Science & Business Media ; 2010
  54. Ziad I; Mille J. Clinical Arrhythmology and Electrophysiology: A Companion to Braunwald's Heart Disease. Saunders ; 2008
  55. Aehlert BJ. ECGs Made Easy - E-Book. Elsevier Health Sciences ; 2015
  56. Rosenbaum, MB; Elizari, MV. Frontiers of Cardiac Electrophysiology: Volume 19 of Developments in Cardiovascular Medicine. Springer Science & Business Media ; 2012
  57. Edhouse J. ABC of clinical electrocardiography: Broad complex tachycardia---Part II. BMJ. 2002; 324 (7340): p.776-779. doi: 10.1136/bmj.324.7340.776 . | Open in Read by QxMD
  58. Field JM. The Textbook of Emergency Cardiovascular Care and CPR. Lippincott Williams & Wilkins ; 2009
  59. Camm AJ, Ward D. Clinical Aspects of Cardiac Arrhythmias. Springer Science & Business Media ; 2012
  60. Wesley K. Huszar's ECG and 12-Lead Interpretation - E-Book. Elsevier Health Sciences ; 2016
  61. Huff J. ECG Workout. Lippincott Williams & Wilkins ; 2006
  62. Dale Dubin, MD. Rapid Interpretation of EKG's. COVER, Inc. ; 2000 : p. 109
  63. Al-Khatib SM, Page RL. Ongoing Management of Patients With Supraventricular Tachycardia. JAMA Cardiology. 2017; 2 (3): p.332. doi: 10.1001/jamacardio.2016.5085 . | Open in Read by QxMD
  64. Ferri FF. Ferri's Clinical Advisor 2020 E-Book. Elsevier Health Sciences ; 2019
  65. Fogoros RN, MD RN. Electrophysiologic Testing. John Wiley & Sons ; 2012

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