What is the treatment for Supraventricular Tachycardia (SVT)?

From the Guidelines

SVT treatment should begin with vagal maneuvers like the Valsalva maneuver or carotid sinus massage as first-line interventions, as recommended by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1.

Key Considerations

• Vagal maneuvers, including Valsalva and carotid sinus massage, can be performed quickly and should be the first-line intervention to terminate SVT, with a success rate of up to 25% 1.
• If vagal maneuvers fail, adenosine is the medication of choice, typically administered as a rapid IV bolus of 6 mg, followed by 12 mg if needed, and another 12 mg dose if the arrhythmia persists, with a success rate of 78-96% 1.
• For ongoing management, calcium channel blockers like verapamil or diltiazem, or beta-blockers such as metoprolol can be effective, with success rates of 80-98% 1.
• In hemodynamically unstable patients, synchronized cardioversion at 50-100 joules is recommended, as it is highly effective in terminating SVT and restoring sinus rhythm 1.

Long-term Management

• Options include daily medications like beta-blockers, calcium channel blockers, or antiarrhythmics, which can help prevent recurrent episodes of SVT.
• Catheter ablation is also a highly effective treatment option, offering a definitive cure with success rates exceeding 95% for most SVT types, and can be considered for patients with frequent or severe episodes of SVT 1.

Important Notes

• The choice of treatment depends on the specific type of SVT, frequency of episodes, patient preferences, and comorbidities.
• SVT occurs due to abnormal electrical conduction pathways or automaticity in the atria or AV node, causing heart rates typically between 150-250 beats per minute, and treatment aims to interrupt these pathways or suppress the abnormal automaticity.
• It is essential to consider the most recent and highest quality study, which in this case is the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1, when making treatment decisions.

From the FDA Drug Label

In patients without structural heart disease, flecainide acetate tablets, USP are indicated for the prevention of: •paroxysmal supraventricular tachycardias (PSVT), including atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia and other supraventricular tachycardias of unspecified mechanism associated with disabling symptoms

Flecainide acetate is indicated for the prevention of paroxysmal supraventricular tachycardias (PSVT) in patients without structural heart disease.

• The use of flecainide acetate for treatment of SVT is not explicitly stated in the label.
• However, it can be used for the prevention of PSVT, which may help in managing the condition.
• It is essential to note that flecainide acetate can cause proarrhythmic effects, and its use should be reserved for patients in whom the benefits outweigh the risks 2.
• The label recommends that the use of flecainide acetate for sustained VT be initiated in the hospital, emphasizing the need for careful titration and monitoring 2.

From the Research

SVT Treatment Options

• Hemodynamically unstable patients with supraventricular tachycardias (SVTs) should be treated with electrical cardioversion 3, 4
• For stable patients, acute termination of tachycardia can be achieved by vagal maneuvers or medical therapy 3, 4, 5
• Vagal maneuvers include the Valsalva maneuver, carotid massage, and ice to the face 3, 4, 6

Vagal Maneuvers

• The Valsalva maneuver and carotid sinus massage (CSM) are commonly used vagal maneuvers to terminate SVT 6
• A study comparing the Valsalva maneuver and CSM found no significant difference in efficacy between the two methods, with a total success rate of 27.7% 6
• Another study found that the Valsalva maneuver achieved reversion rates of 45.9% and 54.3% in laboratory-induced SVT, but only 19.4% in clinical settings 7

Medical Therapy

• Pharmacologic agents such as verapamil, digitalis, and procainamide can be used to treat SVT 4, 5
• Adenosine is also a commonly used medication for terminating SVT 5
• Beta-blockers and calcium channel blockers can be used as alternative therapies 5

Long-term Management

• Long-term treatment of SVT depends on factors such as frequency of symptoms, risk stratification, and patient preference 5
• Management options range from conservative treatment to catheter ablation, which is curative in the majority of patients 5