Carotid sinus massage - after auscultation of both carotid arteries (exclude significant stenosis) - pressure is applied to one carotid sinus for 5 to 10 seconds. Steady pressure is recommended because it may be more reproducible. If the expected response is not obtained, the procedure is repeated on the other side after a one- to two-minute delay.
Valsalva manoeuvres – patient is instructed to exhale forcefully against a closed glottis (against closed mouth and compressed nose) for 10 – 15s and then release.
Modified Valsalva manoeuvre – patient does classical Valsalva manoeuvre followed by 15 seconds of passive leg raise at 45 degree angle – this may be more successful in restoring sinus rhythm.
If vagal manoeuvres are ineffective:
For orthodromic AVRT:
use with caution! – potential induction of atrial fibrillation with fast ventricular conduction or ventricular fibrillation
electrical cardioversion should always be available when administering adenosine
6 mg i.v. as a rapid bolus with saline flush
second dose – 12 mg i.v., safe within 1 min of the last dose
maximum dose = 18 mg
If Adenosine is ineffective > pharmacological therapy directed at AV node:
Pharmacological therapy directed at fast-conducting AP (accessory pathway):
i.v. ibutilide or procainamide
i.v. propafenone or flecainide
The treatment of choice for patients with symptomatic and recurrent AVRT is catheter ablation of accessory pathway
Propafenone or flecainide may be considered in patients with AVRT and without ischaemic or structural heart disease, if ablation is not desirable or feasible
Picture 3 Treatment of AVRT as per ESC guidelines
CAMM, A. J., LÜSCHER, T. F., & SERRUYS, P. W. (2009). The ESC textbook of cardiovascular medicine. Oxford, Oxford University Press
Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomström-Lundqvist C, Calkins H, Corrado D, Deftereos SG, Diller GP, Gomez-Doblas JJ, Gorenek B, Grace A, Ho SY, Kaski JC, Kuck KH, Lambiase PD, Sacher F, Sarquella-Brugada G, Suwalski P, Zaza A; ESC Scientific Document Group. 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. 2020 Feb 1;41(5):655-720. doi: 10.1093/eurheartj/ehz467. PMID: 31504425.