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October 21, 2025 Circulation. 2025;152(suppl 2):S538–S577. DOI: 10.1161/CIR.0000000000001376 S566

Wigginton et al Advanced Life Support: 2025 AHA Guidelines for CPR and ECC

1 B-R 2.  Adenosine is recommended for acute treatment of adult patients with regular narrow-complex tachycardias.

1 B-NR 3.  Synchronized cardioversion is recommended for acute treatment of adult patients with hemodynamically unstable narrow-complex tachycardias.

1 B-NR 4.  Synchronized cardioversion is recommended for acute treatment of adult patients with hemodynamically stable narrow-complex tachycardias when vagal maneuvers and pharmacological therapy is ineffective or contraindicated.

2a B-R 5.  Intravenous diltiazem or verapamil can be effective for acute treatment of adult patients with hemodynamically stable narrow-complex tachycardias that are regular.

2a C-LD 6.  Intravenous β-adrenergic blockers are reasonable for acute treatment of adult patients with hemodynamically stable narrow-complex tachycardias that are regular.

Synopsis In most patients narrow-complex tachycardias (NCTs), which include sinus tachycardia, atrial flutter, AV nodal reentrant tachycardia, AV reentrant tachycardia, and other atrial tachycardia, and previously referred to imprecisely as supraventricular tachycardia, generally are not hemodynamically unstable, and health care professionals have an opportunity to attempt vagal maneuvers. Adenosine may also be effective in terminating arrhythmias in these patients. For hemodynamically unstable patients with NCTs, electrical therapies are warranted (Figure 6). However, there must be a reasonable expectation that the NCT is causing instability rather than being a manifestation of instability caused by another clinical diagnosis (eg, sepsis). Hemodynamically unstable patients with NCT may have hypotension, acutely altered mental status, signs of shock, chest pain, or acute heart failure. Most patients with NCTs have conversion success rates of up to 98% with vagal maneuvers, pharmacological management, or both, described below (eg, adenosine, diltiazem, verapamil). If nasally administered calcium channel blockers become available in the future, they will be evaluated for their efficacy and safety and considered for inclusion in these guidelines and the corresponding treatment algorithm.1–3 These recommendations are supported by the 2015 American College of Cardiology, AHA, and Heart Rhythm Society Guidelines for the Management of Adult Patients With Supraventricular Tachycardia and a 2025 evidence update.

Recommendation-Specific Supportive Text

1.	 The Valsalva maneuver is effective in terminating 20

to 30% of NCTs.4,5 With modified techniques, termination improves to up to 50%.6–9 Vagal maneuvers include having the patient blow into a 10 cc syringe, bearing down, and carotid massage. However, more effective approaches have been described, such as passive leg raise, supine repositioning, and passive leg elevation immediately after Valsalva, blowing into a syringe attached to a sphygmomanometer, and pressing the epigastric region 10 seconds after Valsalva. When performing carotid massage, caution is advised because the technique can precipitate a stroke in patients with carotid atherosclerosis. 2.	 Adenosine has demonstrated very high rates of con-

version of AV nodal reentrant tachycardia, AV reentrant tachycardia, and many atrial tachycardias.10 It also blocks the AV node, confirming a diagnosis of atrial flutter or fibrillation. Adenosine has a very short half-life and may be less effective if infused in a peripheral vein. Adequate dosing is assured by alteration of the NCT, including termination or the patient’s symptoms of flushing and a feeling of dread. Adenosine may have profound effects in patients with central lines or post–heart transplant patients; 1 mg IV may be adequate to terminate the NCT. Adenosine can cause severe bronchospasm in patients with asthma, and thus, is contraindicated. 3.	 In hemodynamically unstable patients with NCT, it

is critical to promptly restore sinus rhythm. If unstable, immediate cardioversion is warranted.11

4 Cardioversion can be used to treat stable patients

with NCT not responsive to vagal maneuvers and pharmacological therapy.11 Assessment of a patient’s mental status and clinical stability is important when the appropriateness of sedation is considered before cardioversion. 5.	 IV diltiazem and verapamil convert NCT to normal sinus rhythm in 64% to 98% of patients. The efficacy of verapamil is similar to adenosine but with significant concerns for inducing hypotension.12–18 Diltiazem and verapamil are particularly useful in patients with recurrent supraventricular tachycardia after treatment with adenosine because they are longer acting. Hypotension is a common side effect, and these medications must be infused slowly.19 For patients with NCT and suspicion of systolic heart failure, diltiazem and verapamil are best avoided. 6.	 Intravenous β-adrenergic blockers are gener-

ally safe and have been shown to terminate NCT in adult patients with hemodynamically stable narrow-complex tachycardias that are regular.

REFERENCES 1.	 Ip JE, Coutu B, Bennett MT, Pandey AS, Stambler BS, Sager P, Chen M, Shardonofsky S, Plat F, Camm AJ. Etripamil Nasal Spray for Conversion of Repeated Spontaneous Episodes of Paroxysmal Supraventricular Tachycardia During Long-Term Follow-Up: Results From the NODE-302 Study. J Am Heart Assoc. 2023;12:e028227. doi: 10.1161/JAHA.122.028227 2.	 Stambler BS, Camm AJ, Alings M, Dorian P, Heidbuchel H, Houtgraaf J, Kowey

PR, Merino JL, Mondesert B, Piccini JP, et al; RAPID Investigators. Self-

Recommendations for the Treatment of Regular Narrow-Complex Tachycardia in Adults (Continued) COR LOE Recommendations

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