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A B C

©ESC 2019

Figure 7 Focal atrial tachycardia. (A) Focal atrial tachycardia originating at the lateral right atrium conducted initially with full and then incomplete right branch bundle block aberration. (B) Focal atrial tachycardia originating at the left atrium (left superior pulmonary vein). (C) Focal atrial tachycardia from the right atrial appendage. Atrioventricular dissociation during carotid sinus massage (P waves indicated by arrows).

Recommendations for the therapy of focal atrial tachycardia

Recommendation Classa Levelb

Acute therapy Haemodynamically unstable patients Synchronized DC cardioversion is recommended for haemodynamically unstable patients.8688 I B Haemodynamically stable patients Adenosine (618 mg i.v. bolus) should be considered.9294 IIa B Beta-blockers (i.v. esmolol or metoprolol) should be considered in the absence of decompensated HF, if adenosine fails.187,188 IIa C Verapamil or diltiazem (i.v.) should be considered for haemodynamically stable patients in the absence of hypotension or HFrEF, if adenosine fails.92,94 IIa C If the above measures fail, the following may be used: • i.v. ibutilide191; • or i.v. flecainide or propafenone189,190; • or i.v. amiodarone.192 IIb C Synchronized DC cardioversion is recommended when drug therapy fails to convert or control the tachycardia.87,88 I B Chronic therapy Catheter ablation is recommended for recurrent focal AT, especially if incessant or causing TCM.184,187,194197 I B Beta-blockers or non-dihydropyridine calcium channel blockers (verapamil or diltiazem in the absence of HFrEF), or propafenone or flecainide in the absence of structural or ischaemic heart disease, should be considered if ablation is not desirable or feasible.188190,198 IIa C Ivabradine with a beta-blocker may be considered if the above measures fail.199,200 IIb C Amiodarone may be considered if the above measures fail.201,202 IIb C

i.v. verapamil and diltiazem are contraindicated in the presence of hypotension or HFrEF. i.v. beta-blockers are contraindicated in the presence of decompensated heart failure. i.v. ibutilide is contraindicated in patients with prolonged QTc interval. i.v. flecainide and propafenone are contraindicated in patients with ischaemic or structural heart disease. They also prolong the QTc interval but much less than class III agents. i.v. amiodarone prolongs the QTc but torsades des pointes is rare. AT = atrial tachycardia; DC = direct current; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; i.v. = intravenous; TCM = tachycardiomyopathy. aClass of recommendation. bLevel of evidence. Downloaded from academic.oup.com/eurheartj/article/41/5/655/5556821 by guest on 07 October 2026