From the Guidelines
For a 56-year-old female with palpitations, normal stress test, Holter monitor, and ECG, but tachycardia with a mean heart rate of 89, the recommended management should start with oral beta blockers, diltiazem, or verapamil for ongoing management, as these are useful in patients with symptomatic SVT who do not have ventricular pre-excitation during sinus rhythm 1.
Initial Management
The patient's symptoms and normal cardiac testing results suggest a potential diagnosis of supraventricular tachycardia (SVT) of unknown mechanism. Given the mean heart rate of 89, which is slightly elevated, initiating therapy with medications that can reduce heart rate and alleviate symptoms is reasonable.
- Oral beta blockers, such as metoprolol or propranolol, can be considered as first-line therapy to reduce heart rate and symptoms.
- Alternatively, diltiazem or verapamil, which are calcium channel blockers, can also be used for their ability to slow the heart rate and reduce the frequency of SVT episodes.
Considerations for Therapy
When selecting a medication, it's essential to consider the patient's overall health, potential side effects, and any contraindications.
- Beta blockers may be preferred in patients with hypertension or those who can benefit from their cardioprotective effects.
- Calcium channel blockers like diltiazem or verapamil may be more suitable for patients with certain types of SVT or those who cannot tolerate beta blockers.
Additional Recommendations
In addition to pharmacological therapy, patients with SVT should be educated on how to perform vagal maneuvers for ongoing management of SVT 1. Vagal maneuvers, such as the Valsalva maneuver or the application of an ice-cold, wet towel to the face, can help terminate SVT episodes and reduce the need for medical attention.
Follow-Up and Monitoring
The patient should be monitored for medication side effects and efficacy, with follow-up in 4-6 weeks to assess symptom improvement and possibly adjust medication dosing if needed. If symptoms persist or worsen, further evaluation, including consideration of electrophysiology (EP) study with the option of ablation, may be necessary. EP study with the option of ablation is useful for the diagnosis and potential treatment of SVT, providing a potential for definitive cure without the need for chronic pharmacological therapy 1.
From the Research
Management of Palpitations
The patient's symptoms of palpitations with a mean heart rate (HR) of 89, despite normal stress test, Holter monitor, and electrocardiogram (ECG) results, require further evaluation.
- The use of beta-blockers, such as metoprolol, has been shown to be effective in maintaining sinus rhythm and controlling ventricular rate in patients with atrial fibrillation 2.
- In patients with palpitations, a 14-day novel adhesive patch electrocardiographic monitoring may be more effective in detecting arrhythmia events compared to a 24-hour Holter monitor 3.
- The analysis of ST segment changes during Holter monitoring should be interpreted with caution, as ST segment depressions can be found in healthy subjects 4.
- Electrophysiological study and ablation may be considered in patients with recurrent palpitations, as it has been shown to be effective in terminating tachycardia 5.
- The patient's symptoms and medical history should be thoroughly evaluated to determine the best course of management, which may include the use of beta-blockers, further monitoring, or other treatments.
- It is essential to consider the patient's overall health and medical history when determining the best management plan, as certain conditions or medications may affect the treatment approach 2, 6.