From the Guidelines
For a 26-year-old patient with supraventricular tachycardia (SVT) at a heart rate of 130 bpm where vagal maneuvers have failed, intravenous adenosine is the next most appropriate step in management, as recommended by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1. If adenosine is ineffective, then intravenous diltiazem or esmolol would be considered. Diltiazem (initial dose 0.25 mg/kg IV over 2 minutes, may repeat with 0.35 mg/kg after 15 minutes if needed) is typically preferred as first-line pharmacological therapy for stable SVT. Esmolol (loading dose of 500 mcg/kg over 1 minute followed by 50-200 mcg/kg/min infusion) is an alternative option, particularly useful in patients with catecholamine-driven SVT. Both medications work by slowing conduction through the AV node, which often terminates the reentrant circuit causing SVT. Some key points to consider when administering these medications include:
- Continuous cardiac monitoring is essential
- Equipment for potential resuscitation should be immediately available
- These medications can cause hypotension or bradycardia as side effects
- Cardioversion would be reserved for hemodynamically unstable patients or when pharmacological management fails, as stated in the guidelines 1.
It's also important to note that the choice between diltiazem and esmolol may depend on the specific clinical scenario and patient characteristics, such as the presence of catecholamine-driven SVT or underlying heart disease. In general, diltiazem is preferred for its longer duration of action and lower risk of side effects, while esmolol is often used in patients with catecholamine-driven SVT or those who require rapid titration of the medication. Ultimately, the decision to use diltiazem or esmolol should be based on the individual patient's needs and the clinical judgment of the healthcare provider.
From the FDA Drug Label
Unless otherwise contraindicated, appropriate vagal maneuvers should be attempted prior to administration of diltiazem hydrochloride injection The use of diltiazem hydrochloride injection or diltiazem hydrochloride for injection should be undertaken with caution when the patient is compromised hemodynamically or is taking other drugs that decrease any or all of the following: peripheral resistance, myocardial filling, myocardial contractility, or electrical impulse propagation in the myocardium Diltiazem Hydrochloride Injection is indicated for: Paroxysmal Supraventricular Tachycardia Rapid conversion of paroxysmal supraventricular tachycardias (PSVT) to sinus rhythm
The next most appropriate step in management for a 26-year-old patient with supraventricular tachycardia (SVT) with a heart rate of 130, after unsuccessful vagal maneuvers, is administration of diltiazem. This is because diltiazem is indicated for the rapid conversion of paroxysmal supraventricular tachycardias (PSVT) to sinus rhythm 2. Cardioversion may also be considered, but the drug label does not provide direct information on its use in this specific scenario. Esmolol is not mentioned in the provided drug label.
From the Research
Management of Supraventricular Tachycardia
The patient is a 26-year-old with supraventricular tachycardia (SVT) and a heart rate of 130, and vagal maneuvers have been unsuccessful. The next most appropriate step in management is to consider pharmacologic interventions.
Pharmacologic Interventions
- Calcium channel blockers, such as diltiazem, can be used to slow the heart rate and convert the arrhythmia to a normal sinus rhythm 3, 4.
- Beta blockers, such as esmolol, can also be used to slow the heart rate and reduce the symptoms of SVT 3, 5.
- Adenosine is another option, but it may not be as effective as calcium channel blockers or beta blockers in this scenario 6, 5.
Cardioversion
- Synchronized cardioversion is typically reserved for patients who are hemodynamically unstable or have not responded to other treatments 7, 6.
- In this case, since the patient is stable and vagal maneuvers have been unsuccessful, pharmacologic interventions should be tried before considering cardioversion.
Treatment Options
- The choice between diltiazem and esmolol depends on the patient's specific clinical scenario and the physician's preference 3, 5.
- Both medications have been shown to be effective in treating SVT, but esmolol may be more suitable for patients with certain comorbidities or those who require a more rapid onset of action 5, 4.