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Yes No

Yes No

No Yes

i.v. adenosine

(I B) i.v. ibutilide or procainamide or i.v. propafenone or flecainide or synchronized, cardioversion

(IIa B)

i.v. verapamil or diltiazem

(IIa B) i.v. beta-blocker

(IIa C) Haemodynamic

instability

Orthodromic

Patient out of hospital

Vagal manoeuvres

(I B)

Vagal manoeuvres

(I B) Synchronized

cardioversion

(I B)

If ineffective If ineffective If ineffective

If ineffective AVRT

Figure 19 Acute therapy of atrioventricular re-entrant tachycardia. AVRT = atrioventricular re-entrant tachycardia; i.v. = intravenous.

Recommendations for the acute therapy of pre-excited atrial fibrillation

Recommendation Classa Levelb

Haemodynamically unstable patients Synchronized DC cardioversion is recommended in haemodynamically unstable patients.86,130 I B Haemodynamically stable patients Ibutilide or procainamide (i.v.) should be considered.421,430,436 IIa B Flecainide or propafenone (i.v.) may be considered.429,431 IIb B Synchronized DC cardioversion is recommended if drug therapy fails to convert or control the tachycardia.86,130 I B Amiodarone (i.v.) is not recommended.432435 III B

i.v. ibutilide is contraindicated in patients with prolonged QTc interval. i.v. procainamide prolongs the QTc interval but much less than class III agents. 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. DC = direct current. aClass of recommendation. bLevel of evidence. Downloaded from academic.oup.com/eurheartj/article/41/5/655/5556821 by guest on 07 October 2026