What is the treatment for Supraventricular Tachycardia (SVT)?

From the Guidelines

The most effective treatment for Supraventricular Tachycardia (SVT) is to start with vagal maneuvers, followed by intravenous adenosine if vagal maneuvers fail, as recommended by the latest guidelines 1. For immediate treatment of an acute SVT episode:

• Start with vagal maneuvers like the Valsalva maneuver or carotid sinus massage, as they are recommended for acute treatment in patients with orthodromic AVRT 1.
• If vagal maneuvers fail, use intravenous adenosine, which is beneficial for acute treatment in patients with orthodromic AVRT, with a success rate of 90% to 95% of patients 1.
• For patients who don't respond to adenosine or have contraindications, consider alternative treatments, but note that verapamil and diltiazem are no longer recommended as first-line treatments for acute management of narrow-QRS tachycardias 1. For long-term management:
• Beta-blockers may be used for prevention, but their strength of recommendation has been downgraded for certain types of SVT 1.
• For frequent or severe episodes, catheter ablation may be recommended, as it can interrupt the reentry circuit and prevent future episodes. It's essential to consider underlying causes (e.g., hyperthyroidism, electrolyte imbalances) and address them as part of the treatment plan. The latest guidelines from 2020 1 provide updated recommendations for the management of SVT, including the use of ivabradine and the downgrading of certain anti-arrhythmic drugs.

From the FDA Drug Label

Esmolol hydrochloride injection is indicated for the short-term treatment of: Control of ventricular rate in supraventricular tachycardia including atrial fibrillation and atrial flutter and control of heart rate in noncompensatory sinus tachycardia Administer intravenously Titrate using ventricular rate or blood pressure at ≥ 4 minute intervals Supraventricular tachycardia (SVT) or noncompensatory sinus tachycardia Optional loading dose: 500 mcg per kg infused over one minute Then 50 mcg per kg per minute for the next 4 minutes Adjust dose as needed to a maximum of 200 mcg per kg per minute Additional loading doses may be administered

The treatment for Supraventricular Tachycardia (SVT) is esmolol hydrochloride injection administered intravenously, with a possible loading dose of 500 mcg per kg infused over one minute, followed by a maintenance dose of 50 mcg per kg per minute, adjusted as needed to a maximum of 200 mcg per kg per minute 2, 2.

• Key points:
  • Administer intravenously
  • Titrate using ventricular rate or blood pressure at ≥ 4 minute intervals
  • Maximum dose: 200 mcg per kg per minute
  • Additional loading doses may be administered
  • Esmolol hydrochloride injection is indicated for the short-term treatment of SVT 2, 2

From the Research

Treatment Options for Supraventricular Tachycardia (SVT)

The treatment for SVT can be categorized into nonpharmacologic, pharmacologic, and electrical methods.

• Nonpharmacologic treatments aim to increase vagal tone and include:
  • Vagal maneuvers (VagMs) such as carotid sinus massage and Valsalva maneuver 3, 4, 5, 6, 7
  • Head-down tilt and activation of the diving reflex 4
  • Use of the pneumatic antishock garment 4
• Pharmacologic treatments include:
  • Verapamil, which is considered the most effective currently available pharmacologic agent 4
  • Digitalis for hemodynamically stable patients whose PSVTs are refractory to verapamil 4
  • Procainamide for patients with antegrade accessory pathway conduction and a history of atrial fibrillation 4
  • Adenosine or beta-blockers for patients who do not respond to vagal maneuvers 5
• Electrical treatments include:
  • Synchronized electrical countershock, which is the treatment of choice for hemodynamically unstable patients 4
  • Electrical cardioversion, which has proven to be efficacious and safe in all trimesters for patients who are refractory to pharmacologic management and hemodynamically unstable 5

Recommended Treatment Approach

• The initial treatment for hemodynamically stable patients is to attempt vagal maneuvers, such as carotid sinus massage or Valsalva maneuver 3, 5
• If the SVT does not convert to normal sinus rhythm, treatment with adenosine or beta-blockers may be initiated 5
• The modified Valsalva maneuver (MVM) is recommended as the first choice of VagM for rhythm conversion before pharmacological management of SVT 3
• Clinical decision analysis indicates that young patients should be treated initially with vagal maneuvers, but older patients (above approximately 65 years of age) should be treated initially with verapamil 7