What is the next best treatment plan for a 22-year-old female with supraventricular tachycardia (sVT) versus atrial tachycardia diagnosed on a Holter (holter) monitor?

From the Guidelines

The next best treatment plan for a 22-year-old female with supraventricular tachycardia (SVT) versus atrial tachycardia detected on Holter monitoring is to first attempt vagal maneuvers, such as the modified Valsalva maneuver, to terminate the arrhythmia. If these maneuvers are unsuccessful, intravenous adenosine (6 mg rapid IV push, followed by 12 mg if needed) is recommended as the first-line pharmacological treatment during an acute episode, as it can acutely terminate AVNRT in approximately 95% of patients and unmask atrial activity in arrhythmias, such as atrial flutter or AT 1. For long-term management, a cardiology referral for electrophysiology study and possible catheter ablation is recommended, especially in a young patient where this offers potential cure. If ablation is not immediately feasible, beta-blockers such as metoprolol (25-100 mg twice daily) or calcium channel blockers like diltiazem (120-360 mg daily in divided doses) can be used for symptom control, as they are effective in converting AVNRT to sinus rhythm and have an excellent safety profile 1. Some key points to consider in the management of SVT include:

• Vagal maneuvers should be performed with the patient in the supine position, and there is no "gold standard" for proper Valsalva maneuver technique, but in general, the patient raises intrathoracic pressure by bearing down against a closed glottis for 10 to 30 seconds, equivalent to at least 30 mm Hg to 40 mm Hg 1.
• Adenosine can be considered as both a therapeutic and diagnostic agent in narrow-complex tachyarrhythmias, and it will acutely terminate AVNRT in approximately 95% of patients and will unmask atrial activity in arrhythmias, such as atrial flutter or AT 1.
• Synchronized cardioversion should be performed for acute treatment in hemodynamically unstable patients with AVNRT when adenosine and vagal maneuvers do not terminate the tachycardia or are not feasible, and it is highly effective in terminating SVT (including AVRT and AVNRT) 1. The patient should be educated about avoiding triggers such as caffeine, alcohol, and stress. This approach is recommended because SVT in young patients is often due to an accessory pathway or AV nodal reentry, which responds well to ablation with high success rates and low complication risks, offering a definitive solution rather than lifelong medication.

From the FDA Drug Label

In two randomized, crossover, placebo-controlled, double-blind trials of 60–90 days duration in patients with paroxysmal supraventricular arrhythmias [paroxysmal atrial fibrillation/flutter (PAF), or paroxysmal supraventricular tachycardia (PSVT)], propafenone reduced the rate of both arrhythmias...

The next best treatment plan for a 22-year-old female with supraventricular tachycardia (sVT) vs atrial tach could be propafenone (PO), as it has been shown to reduce the rate of paroxysmal supraventricular tachycardia (PSVT) in clinical trials 2.

• The patient's age and diagnosis should be taken into consideration when deciding on a treatment plan.
• Propafenone may be a suitable option, but it is essential to weigh the potential benefits and risks, especially considering the patient's age and the fact that the clinical trials had a mean age of 57.3 years 2.

From the Research

Diagnosis and Treatment Plan

The patient's Holter monitor results indicate supraventricular tachycardia (sVT) versus atrial tachycardia. The next best treatment plan would involve:

• Vagal maneuvers as the first-line treatment to terminate the arrhythmia 3, 4, 5
• If vagal maneuvers are ineffective, adenosine can be used in the acute setting to manage the condition 3, 4
• For long-term therapy, calcium channel blockers (diltiazem or verapamil) or beta blockers (metoprolol) can be used 3, 4
• Class Ic antiarrhythmics (flecainide or propafenone) can also be used for long-term therapy 3
• Referral to a cardiologist for electrophysiologic study and possible catheter ablation, which has a high success rate and is recommended for recurrent, symptomatic paroxysmal SVT 3, 4, 5

Considerations for Long-Term Management

The patient's long-term management plan should be based on factors such as:

• Frequency of symptoms
• Risk stratification
• Patient preference 4, 5
• The use of a patient-centered approach to formulate a long-term management plan 5