What are the management options for Supraventricular Tachycardia (SVT)?

From the Guidelines

The most effective management option for Supraventricular Tachycardia (SVT) is to attempt vagal maneuvers first, followed by adenosine if necessary, and consider catheter ablation for long-term definitive treatment, as recommended by the 2020 European Heart Journal guidelines 1.

Acute Management

For acute termination of SVT, the following options are available:

• Vagal maneuvers, such as the Valsalva maneuver or carotid sinus massage, to increase parasympathetic tone and slow conduction through the AV node 1
• Adenosine, typically given as a rapid IV bolus of 6 mg, followed by 12 mg if needed, with doses repeated up to 12 mg if necessary, to temporarily block AV node conduction 1
• Alternative acute medications, such as calcium channel blockers (verapamil 5-10 mg IV or diltiazem 0.25 mg/kg IV) or beta-blockers (esmolol 500 μg/kg IV or metoprolol 5 mg IV) 1

Long-term Management

For long-term management of SVT, the following options are available:

• Catheter ablation, which offers definitive treatment with success rates exceeding 95% for most SVT types 1
• Chronic medication therapy with beta-blockers (metoprolol 25-100 mg twice daily), calcium channel blockers (diltiazem 120-360 mg daily), or class IC antiarrhythmics like flecainide (50-200 mg twice daily) for patients with structurally normal hearts 1 The choice between ablation and medication depends on frequency of episodes, patient preference, medication tolerance, and underlying cardiac conditions.

Special Considerations

For hemodynamically unstable patients, synchronized cardioversion at 50-100 joules is recommended 1. It is essential to educate patients on how to perform vagal maneuvers for ongoing management of SVT, as they can help terminate the arrhythmia and reduce the need for medical attention 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 2

• Management options for Supraventricular Tachycardia (SVT) include the use of flecainide acetate tablets for the prevention of paroxysmal supraventricular tachycardias (PSVT) in patients without structural heart disease.
• Flecainide acetate tablets are also indicated for the prevention of paroxysmal atrial fibrillation/flutter (PAF) associated with disabling symptoms.
• Key considerations for the use of flecainide acetate tablets include the potential for proarrhythmic effects, and the need for careful titration and monitoring, particularly in patients with sustained VT and serious underlying heart disease.
• Another option is propafenone, which has been shown to reduce the rate of both paroxysmal atrial fibrillation/flutter (PAF) and paroxysmal supraventricular tachycardia (PSVT) in clinical trials 3

From the Research

Management Options for Supraventricular Tachycardia (SVT)

The management of SVT can be categorized into several approaches, including nonpharmacologic, pharmacologic, and electrical methods.

• Nonpharmacologic treatments aim to increase vagal tone and include techniques such as:
  • Vagal maneuvers (e.g., Valsalva maneuver, carotid massage, ice to the face) 4, 5
  • Novel vagal maneuver techniques, such as quickly lying backward from a seated position 4
• Pharmacologic treatments involve the use of medications to terminate SVT episodes or prevent recurrence.
  • Adenosine is commonly used for acute termination of SVT 6, 7
  • Calcium channel blockers (e.g., verapamil, diltiazem) can be effective in converting SVT to a normal sinus rhythm, especially when administered as a slow infusion 8
  • Other medications, such as digitalis and procainamide, may be used in specific cases or when first-line treatments are ineffective 5, 7

Electrical Cardioversion

• Electrical cardioversion is a procedure used to convert an abnormal heart rhythm back to a normal sinus rhythm using electrical shocks.
• It is typically reserved for hemodynamically unstable patients with SVT or those who have not responded to other treatments 4, 5, 6, 7

Catheter Ablation

• Catheter ablation is a minimally invasive procedure that involves destroying the abnormal electrical pathways in the heart that are causing SVT.
• It is often recommended for patients with recurrent or symptomatic SVT, particularly those with atrioventricular nodal re-entrant tachycardia or other reentrant arrhythmias 6, 7