From the Guidelines
As-needed treatment options for supraventricular tachycardia (SVT) should start with vagal maneuvers, followed by adenosine if necessary, and cardioversion for hemodynamically unstable patients, as recommended by the most recent guidelines 1. The treatment of SVT involves several strategies, including:
- Vagal maneuvers: These are first-line interventions that patients can perform themselves, including the Valsalva maneuver, carotid sinus massage, facial immersion in cold water, or coughing, as supported by the 2015 ACC/AHA/HRS guideline 1.
- Adenosine: If vagal maneuvers fail, adenosine is the medication of choice, administered as a rapid IV bolus of 6 mg, followed by a 12 mg dose if needed, and potentially a second 12 mg dose if the arrhythmia persists, as recommended by the 2020 ESC guidelines 1.
- Cardioversion: For hemodynamically unstable patients, synchronized cardioversion at 50-100 joules is recommended, as stated in the 2015 ACC/AHA/HRS guideline 1.
- Alternative medications: Calcium channel blockers like verapamil or diltiazem, or beta-blockers such as metoprolol, may be used in certain cases, but their use has been downgraded in recent guidelines 1. It is essential to prioritize the patient's safety and well-being, and to involve them in the decision-making process, considering their preferences and goals for therapy, as emphasized in the 2015 ACC/AHA/HRS guideline 1. Key points to consider when treating SVT include:
- The importance of proper vagal maneuver techniques and patient education on when to seek emergency care if SVT episodes don't resolve or are accompanied by severe symptoms.
- The need for synchronized cardioversion in hemodynamically unstable patients.
- The use of adenosine as the first-line medication for SVT, with alternative medications available for specific cases.
- The involvement of the patient in the decision-making process and consideration of their unique physical, psychological, and social situation.
From the FDA Drug Label
For the treatment of supraventricular tachycardia, maintenance infusion dosages greater than 200 mcg per kg per min are not recommended; dosages greater than 200 mcg per min provide little additional heart rate-lowering effect, and the rate of adverse reactions increases The effective maintenance dose for continuous and step-wise dosing is 50 to 200 mcg per kg per minute, although doses as low as 25 mcg per kg per minute have been adequate
The as-needed treatment options for Supraventricular Tachycardia (SVT) include:
- Esmolol (IV):
- Maintenance infusion dosages of 50 to 200 mcg per kg per minute
- Doses as low as 25 mcg per kg per minute have been adequate
- Diltiazem (IV):
- Can be used for transition to further antiarrhythmic therapy
- Therapy with antiarrhythmic agents to maintain reduced heart rate in atrial fibrillation or atrial flutter or for prophylaxis of PSVT was generally started within 3 hours after bolus administration of diltiazem hydrochloride injection 2 Note: The information provided is based on the available drug labels and may not be exhaustive or definitive. Consult the respective manufacturer's package insert for more information relative to dosage and administration 3, 3, 2
From the Research
As-Needed Treatment Options for SVT
The following are as-needed treatment options for supraventricular tachycardia (SVT):
- Vagal maneuvers, which are recommended as the first-line treatment for SVT 4
- Pharmacologic therapy, which is commonly used for the acute treatment and termination of paroxysmal SVT 5
- Intravenous administration of adenosine or verapamil, which can effectively terminate PSVT 6
- Slow infusion of calcium channel blockers, such as verapamil and diltiazem, which can be an alternative to adenosine in the emergency treatment of stable patients with SVT 7
Vagal Maneuvers
Vagal maneuvers include:
- Modified Valsalva maneuver (MVM), which is the most effective VagM after initial performance and at the end of study 4
- Carotid sinus massage (CSM), which has a lower conversion rate to sinus rhythm compared to MVM 4
- Standard Valsalva maneuver, which does not elicit better conversion rate to sinus rhythm than CSM 4
- A novel vagal maneuver technique that involves quickly lying backward from a seated position, which can increase vagal stimulation and terminate SVT episodes 8
Pharmacologic Therapy
Pharmacologic agents commonly used in the acute and chronic treatment of SVT include:
- Adenosine, which is effective in terminating PSVT but can be expensive 6
- Verapamil, which is effective in terminating PSVT but can cause hypotension 6
- Diltiazem, which is highly effective and safe for terminating PSVT 6
- Esmolol, which has poor efficacy for terminating PSVT 6
Calcium Channel Blockers
Calcium channel blockers, such as verapamil and diltiazem, can be administered through slow infusion, which: