Paroxysmal Supraventricular Tachycardia Treatment & Management

  • Author: Monika Gugneja, MD; Chief Editor: Jeffrey N Rottman, MD   more...
 
Updated: Jan 23, 2012
 

Medical Care

Most of the patients who present with paroxysmal supraventricular tachycardia have AVNRT or AVRT. These arrhythmias depend on AV nodal conduction and therefore can be terminated by transiently blocking AV nodal conduction.

Vagal maneuvers are the first-line treatment in hemodynamically stable patients. Vagal maneuvers, such as breath-holding and the Valsalva maneuver (ie, having the patient bear down as though having a bowel movement), all slow conduction in the AV node and can potentially interrupt the reentrant circuit.

Carotid massage is another vagal maneuver that can slow AV nodal conduction. Massage the carotid sinus for several seconds on the nondominant cerebral hemisphere side. This maneuver is usually reserved for young patients. Due to the risk of stroke from emboli, auscultate for bruits before attempting this maneuver. Do not perform carotid massage on both sides. A Valsalva maneuver, if performed properly by the patient, can frequently avert an attack.

Synchronized cardioversion starting at 50 J can be used immediately in patients who are hypotensive, have pulmonary edema, have chest pain with ischemia, or are otherwise unstable.

  • Short-term medical management
    • When SVT is not terminated by vagal maneuvers, short-term management involves intravenous adenosine or calcium channel blockers. Adenosine is a short-acting drug that blocks AV node conduction; it terminates 90% of tachycardias due to AVNRT or AVRT.[40, 34, 46, 47, 41] Adenosine does not usually terminate atrial tachycardia, although it is effective for terminating SNRT.[40, 34, 46, 48, 41] Typical adverse effects of adenosine include flushing, chest pain, and dizziness. These effects are temporary because adenosine has a very short half-life of 10-20 seconds.[49]
    • Other alternatives for the acute treatment of SVT include calcium channel blockers like verapamil, diltiazem or beta-blockers like metoprolol or esmolol. Verapamil is a calcium channel blocker that also has AV blocking properties. Verapamil has a longer half-life than adenosine and may help maintain sinus rhythm following the termination of SVT. It is also advantageous for controlling the ventricular rate in patients with atrial tachyarrhythmia.[23, 50, 46, 51, 11, 48, 49, 20]
    • Acute management of a wide complex tachycardia in a hemodynamically unstable patient requires immediate cardioversion whereas in a stable patient, IV procainamide, propafenone, or flecainide is acceptable. Amiodarone is preferred in patients with impaired left ventricular function or in patients with heart failure or structural heart disease.[52]
    • Treatment of AF and atrial flutter involves controlling the ventricular rate, restoring the sinus rhythm, and preventing embolic complications. The ventricular rate is controlled with calcium channel blockers, digoxin, amiodarone, and beta-blockers. The sinus rhythm may be restored with either pharmacological agents or electrical cardioversion. Pharmacological agents such as ibutilide convert AF and atrial flutter of short duration to sinus rhythm in approximately 30% and 60% of patients, respectively.
    • Electrical cardioversion is the most effective method for restoring sinus rhythm. If AF has been present for longer than 24-48 hours, defer cardioversion until the patient has been adequately anticoagulated to prevent thromboembolic complications.[40, 34, 46, 51, 53, 48, 49, 41]
  • Long-term medical management
    • The choice of long-term therapy for patients with SVT depends on the type of tachyarrhythmia and the frequency and duration of episodes, symptoms, and risks associated with the arrhythmia (eg, heart failure, sudden death). Evaluate patients on an individual basis, and tailor the best therapy for the specific tachyarrhythmia.
    • Patients with paroxysmal supraventricular tachycardia may initially be treated with calcium channel blockers, digoxin, and/or beta-blockers. Class IA, IC, or III antiarrhythmic agents are used less frequently because of the success of radiofrequency catheter ablation.[40, 34, 46, 51, 53, 48, 49, 41, 54] Consider radiofrequency ablation for any patient with symptomatic paroxysmal supraventricular tachycardia in whom long-term medical treatment is not effectively tolerated or desired. In addition, because of the risk of sudden cardiac death, perform catheter ablation on patients with symptomatic WPW syndrome. Radiofrequency catheter ablation is more than 90% effective in curing paroxysmal supraventricular tachycardia.[23, 40, 11, 41, 8]
    • Radiofrequency ablation involves focally ablating the crucial component of the arrhythmia mechanism. For example, in AVNRT, the slow pathway is ablated, which prevents the reentry cycle. The accessory pathway is targeted in patients with AVRT. Focal atrial tachycardia, atrial flutter, and, in some cases, AF can also be cured with ablation. Radiofrequency ablation has a high success rate and is performed using conscious sedation in an outpatient setting or with overnight hospitalization. Complications, which occur at a rate of 1-3%, include deep vein thrombosis, systemic embolism, infection, cardiac tamponade, and hemorrhage. The risk of death is approximately 0.1%. The lifetime risk of fatal malignancy as a result of radiation exposure is low.
    • Radiofrequency ablation is cost-effective for patients who have frequent episodes of SVT that require antiarrhythmic agents and frequent emergency visits. It is also indicated for patients with incessant tachycardia and for patients with symptomatic WPW syndrome. The optimal management strategy for patients with asymptomatic preexcitation syndromes remains uncertain.[55, 56, 15, 23, 8]
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Surgical Care

Prior to the advent of percutaneous radiofrequency catheter ablation, open cardiac surgical procedures were the only means of curing paroxysmal supraventricular tachycardia. Currently, open surgical procedures are rarely performed.

Bohnen et al performed a prospective study to assess the incidence and predictors of major complications from contemporary catheter ablation procedures. Major complication rates ranged between 0.8% (supraventricular tachycardia) and 6% (ventricular tachycardia associated with structural heart disease), depending on the ablation procedure performed. They reported renal insufficiency was the only independent predictor of a major complication.[57]

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Consultations

  • A cardiologist should be consulted for patients with frequent episodes of paroxysmal supraventricular tachycardia, syncope, and/or preexcitation syndromes.
  • Consultation with a cardiologist should also be obtained for patients in whom medical management has failed.
  • An electrophysiologist should be consulted for patients considered for radiofrequency catheter ablation.
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Diet

Dietary changes depend on underlying medical problems.

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Activity

Changes in physical activity depend on underlying cardiac problems and other comorbidities.

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Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Monika Gugneja, MD  Consulting Staff, Department of Emergency Medicine, William Beaumont Hospital

Disclosure: Nothing to disclose.

Coauthor(s)

Phillip L Kraft, MD  Director, Interventional Cardiology and Cardiac Catheterization Laboratory, William Beaumont Hospital

Phillip L Kraft, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, and Michigan State Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Alan D Forker, MD  Professor of Medicine, University of Missouri at Kansas City School of Medicine; Director, Outpatient Lipid Diabetes Research, MidAmerica Heart Institute of St Luke's Hospital

Alan D Forker, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, American Society of Hypertension, and Phi Beta Kappa

Disclosure: Research Grant Grant/research funds Hospital contracts to do research; I am a hospital employee with no personal profit; Speakers Bureau Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Brian Olshansky, MD  Professor of Medicine, Department of Internal Medicine, University of Iowa College of Medicine

Brian Olshansky, MD is a member of the following medical societies: American Autonomic Society, American College of Cardiology, American College of Chest Physicians, American College of Physicians, American College of Sports Medicine, American Federation for Clinical Research, American Heart Association, Cardiac Electrophysiology Society, Heart Rhythm Society, and New York Academy of Sciences

Disclosure: Guidant/Boston Scientific Honoraria Speaking and teaching; Medtronic Honoraria Speaking and teaching; Guidant/Boston Scientific Consulting fee Consulting; Novartis Honoraria Speaking and teaching; Novartis Consulting fee Consulting

Amer Suleman, MD  Private Practice

Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Chief Editor

Jeffrey N Rottman, MD  Professor of Medicine and Pharmacology, Vanderbilt University School of Medicine; Chief, Department of Cardiology, Nashville Veterans Affairs Medical Center

Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association and North American Society of Pacing and Electrophysiology (NASPE)

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author James V Talano, MD to the development and writing of this article.

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Sinus tachycardia. Note that the QRS complexes are narrow and regular. The patient's heart rate is approximately 135 bpm. P waves are normal in morphology.
Atrial tachycardia. The patient's heart rate is 151 bpm. P waves are upright in lead V1.
Multifocal atrial tachycardia. Note the different P-wave morphologies and irregularly irregular ventricular response.
Atrial flutter. The patient's heart rate is approximately 135 bpm with 2:1 conduction. Note the sawtooth pattern formed by the flutter waves.
Atrial fibrillation. The patient's ventricular rate varies from 130-168 bpm. Rhythm is irregularly irregular. P waves are not discernible.
Atrioventricular nodal reentrant tachycardia. The patient's heart rate is approximately 146 bpm with a normal axis. Note the pseudo S waves in leads II, III, and aVF. Also note the pseudo R' waves in V1 and aVR. These deflections represent retrograde atrial activation.
Same patient as in Media file 6. Patient is in sinus rhythm following atrioventricular nodal reentrant tachycardia.
Image A displays the slow pathway and the fast pathway, with a regular impulse being conducted through the atrioventricular node. Image B displays a premature impulse that is conducted in an anterograde manner through the slow pathway and in a retrograde manner through the fast pathway, as is seen in typical atrioventricular nodal tachycardia. Image C displays the premature impulse conducting in a retrograde manner through the pathway and the impulse reentering the pathway with anterograde conduction, which is seen commonly in patients with atypical atrioventricular nodal tachycardia.
Wolff-Parkinson-White pattern. Note the short PR interval and slurred upstroke (delta wave) to the QRS complexes.
The left image displays the atrioventricular node with the accessory pathway. The impulse is conducted in an anterograde manner in the atrioventricular node and in a retrograde manner in the accessory pathway. This circuit is known as orthodromic atrioventricular reentrant tachycardia and can occur in patients with concealed accessory tracts or Wolff-Parkinson-White syndrome. The right image displays the impulse being conducted in an anterograde manner through the accessory pathway and in a retrograde manner via the atrioventricular node. This type of circuit is known as antidromic atrioventricular reentrant tachycardia and only occurs in patients with Wolff-Parkinson-White syndrome. Both patterns may display retrograde P waves after the QRS complexes.
Orthodromic atrioventricular reentrant tachycardia. This patient has Wolff-Parkinson-White syndrome.
The left panel depicts antidromic atrioventricular reentrant tachycardia. The right panel depicts sinus rhythm in a patient with antidromic atrioventricular reentrant tachycardia. Note that the QRS complex is an exaggeration of the delta wave during sinus rhythm.
Atrial fibrillation in a patient with Wolff-Parkinson-White syndrome. Note the extremely rapid ventricular rate and variability in QRS morphology. Several minutes later, the patient developed ventricular fibrillation.
 
 
 
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