For stable patients with narrow complex tachycardia in primary care, the recommended pharmacological treatments primarily focus on rate control using standard beta-blockers (excluding sotalol) or rate-limiting calcium-channel blockers such as diltiazem or verapamil, unless contraindicated. Digoxin monotherapy may be considered for patients who do little or no physical exercise or when other rate-control drugs are unsuitable. If monotherapy fails to control symptoms due to poor ventricular rate control, combination therapy using any two of beta-blocker, diltiazem, and digoxin can be considered. Specialist advice should be sought before combining diltiazem with beta-blockers due to risks of bradycardia and atrioventricular block. If symptoms persist despite adequate rate control, prompt cardiology referral within 4 weeks is recommended for further management, including consideration of rhythm control strategies or ablation. Amiodarone is generally reserved for specialist use, particularly in patients with left ventricular impairment or heart failure, and is not recommended for long-term rate control in primary care.
Key points:
- First-line rate control: standard beta-blocker or rate-limiting calcium-channel blocker (diltiazem/verapamil) NICE NG196.
- Digoxin monotherapy for sedentary patients or when other drugs contraindicated NICE NG196.
- Combination therapy (beta-blocker + diltiazem or digoxin) if monotherapy insufficient NICE NG196.
- Specialist advice before combining diltiazem with beta-blockers due to serious risks NICE NG196.
- Refer to cardiology if symptoms uncontrolled despite treatment NICE NG196.
- Amiodarone reserved for specialist use, not for routine primary care rate control NICE CKS,NICE NG196.