What is the treatment for a patient with a normal Holter (Holter monitor) report, except for one episode of Supraventricular Tachycardia (SVT) lasting 35 seconds?

From the Guidelines

For a patient with a Holter monitor showing normal findings but one episode of supraventricular tachycardia (SVT) lasting 35 seconds, the first-line treatment for acute termination of SVT episodes should include vagal maneuvers, such as the Valsalva maneuver or carotid sinus massage, as recommended by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1.

Treatment Approach

When considering treatment for this patient, several factors come into play, including the presence of symptoms, the frequency and duration of SVT episodes, and the patient's overall cardiac health.

• Vagal maneuvers are recommended as the initial approach for terminating SVT episodes due to their simplicity, rapid effectiveness, and low risk of complications 1.
• If vagal maneuvers are unsuccessful, adenosine can be considered as a next step for acute treatment, given its high success rate in converting SVT to sinus rhythm, although it may cause brief side effects in some patients 1.

Considerations for Ongoing Management

• For patients who experience recurrent or symptomatic SVT episodes, further evaluation and consideration of preventive therapies such as beta-blockers or calcium channel blockers may be necessary.
• The decision to proceed with more invasive treatments like catheter ablation should be based on the severity of symptoms, the frequency of episodes, and the patient's preference after discussing the risks and benefits.

Quality of Life and Morbidity Considerations

• The primary goal of treatment in this context is not only to reduce the frequency and severity of SVT episodes but also to improve the patient's quality of life by minimizing symptoms and reducing the risk of complications associated with untreated SVT.
• Given that SVT is generally benign but can significantly impact quality of life when symptomatic, a tailored approach to management that balances the risks and benefits of different treatment strategies is essential 1.

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

The patient has a normal Holter finding with one episode of SVT for 35 seconds. Given that the patient has SVT, which is a type of paroxysmal supraventricular tachycardia (PSVT), and assuming the patient has disabling symptoms, treatment with flecainide acetate may be considered, as it is indicated for the prevention of PSVT in patients without structural heart disease 2. However, it is crucial to weigh the benefits and risks of treatment, considering the potential proarrhythmic effects of flecainide acetate, especially in patients with underlying heart disease 2.

Key considerations for treatment:

• The patient's symptoms and the impact of the SVT episode on their daily life
• The presence of any underlying heart disease or structural abnormalities
• The potential risks and benefits of treatment with flecainide acetate

Given the information provided, it is essential to consult with a healthcare professional to determine the best course of treatment for this patient.

From the Research

Treatment Options for SVT

• Vagal maneuvers may be used to terminate the arrhythmia, as they are often effective in the acute setting 3, 4, 5
• If vagal maneuvers fail, adenosine may be used to terminate the arrhythmia 3, 5
• Calcium channel blockers (diltiazem or verapamil) or beta blockers (metoprolol) can be used acutely or as long-term therapy 3, 4
• Class Ic antiarrhythmics (flecainide or propafenone) can be used long-term 3
• Catheter ablation has a high success rate and may be recommended for long-term management of recurrent, symptomatic paroxysmal SVT 3, 4, 5

Predicting Induction and Ablation of SVT

• Five preoperative findings can predict a high probability of SVT induction and ablation at electrophysiological study (EPS):
  • A characteristic EKG recording of SVT
  • Termination of SVT with adenosine
  • Termination of SVT or symptoms with vagal maneuvers
  • An episode of SVT lasting ≥ 30 s on a monitor recording
  • Pre-excitation on the baseline EKG 6
• In this case, the patient had one episode of SVT for 35 seconds, which meets the fourth criterion and may indicate a high probability of SVT induction and ablation at EPS 6