Focal Atrial Tachycardia Without Haemodynamic Instability — What to Do When Adenosine Has Not Terminated the Arrhythmia
This protocol addresses the haemodynamically stable patient with focal atrial tachycardia in whom the initial adenosine attempt did not terminate the arrhythmia and a next clinical step is needed.
Clinical scenario
Focal atrial tachycardia (AT) is an organised atrial rhythm arising from a discrete origin, spreading centrifugally over both atria. The patient is haemodynamically stable — no signs of haemodynamic instability are present.
Previous step — failure condition
The first-line approach for haemodynamically stable focal atrial tachycardia is adenosine. When adenosine does not achieve termination of the atrial tachycardia, management must escalate to the protocol below.
Next-step approach (partial)
The next step involves an intravenous agent selected according to the patient's haemodynamic and cardiac profile. The choice between available agent classes — and the contraindications that govern that choice — is detailed in the full protocol.
Treatment goals
Termination of the focal atrial tachycardia or slowing of the ventricular rate.
References
DOI: 10.1093/eurheartj/ehz827
- Focal AT is defined as an organized atrial rhythm ≥100 b.p.m. initiated from a discrete origin and spreading over both atria in a centrifugal pattern.
- Beta-blockers (i.v. esmolol or metoprolol) should be considered in the absence of decompensated HF, if adenosine fails.
- Verapamil or diltiazem (i.v.) should be considered for haemodynamically stable patients in the absence of hypotension or HFrEF, if adenosine fails.
- In general, acute therapy may be initiated with beta-blockers or calcium channel blockers, which may terminate focal ATs or slow the ventricular rate (Figure 8).
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