What is the treatment for Paroxysmal Supraventricular Tachycardia (PSVT)?

From the Guidelines

Paroxysmal supraventricular tachycardia (PSVT) treatment begins with vagal maneuvers like the Valsalva maneuver or carotid sinus massage to slow the heart rate, as recommended by the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1. If these fail, intravenous adenosine is the first-line medication, typically given as a 6 mg rapid bolus followed by a 12 mg dose if needed, as supported by the 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1. For patients with recurrent episodes, calcium channel blockers like verapamil (5-10 mg IV) or diltiazem (0.25 mg/kg IV), or beta-blockers such as metoprolol (5 mg IV) may be used, as suggested by the 2015 ACC/AHA/HRS guideline 1. Some key points to consider in the treatment of PSVT include:

• Vagal maneuvers are a non-invasive and effective way to terminate PSVT, with a success rate of up to 25% 1.
• Adenosine is a safe and effective medication for terminating PSVT, with a rapid onset of action and few severe side effects 1.
• Calcium channel blockers and beta-blockers can be used to prevent recurrences of PSVT, and are often used in combination with vagal maneuvers and adenosine 1.
• Catheter ablation is a highly effective treatment for PSVT, with success rates exceeding 95%, and is often recommended for patients with recurrent episodes 1. In emergency situations with hemodynamic instability, synchronized cardioversion at 50-100 joules is recommended, as supported by the 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1. For long-term management, daily oral medications like beta-blockers (metoprolol 25-100 mg twice daily), calcium channel blockers (diltiazem 30-60 mg three to four times daily), or antiarrhythmics like flecainide (50-200 mg twice daily) can prevent recurrences, as suggested by the 2015 ACC/AHA/HRS guideline 1. These treatments work by interrupting the reentry circuit that causes PSVT, either by temporarily blocking the AV node (adenosine), slowing conduction (calcium channel blockers, beta-blockers), or by permanently disrupting the abnormal pathway (ablation) 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

The treatment for Paroxysmal Supraventricular Tachycardia (PSVT) is flecainide acetate tablets, USP for prevention in patients without structural heart disease.

• Key points:
  • Flecainide acetate tablets, USP are indicated for the prevention of PSVT.
  • The use of flecainide acetate tablets, USP should be reserved for patients in whom the benefits of treatment outweigh the risks.
  • Flecainide acetate tablets, USP should not be used in patients with recent myocardial infarction.

From the Research

Treatment Options for Paroxysmal Supraventricular Tachycardia (PSVT)

The treatment for PSVT can be categorized into nonpharmacologic, pharmacologic, and electrical methods 3.

• Nonpharmacologic Treatments: These methods increase vagal tone and include:
  • Vagal maneuvers such as the Valsalva maneuver 4, 3, 5, 6, 7
  • Carotid sinus massage 3, 6, 7
  • Head-down tilt 3, 7
  • Activation of the diving reflex 3
  • Use of the pneumatic antishock garment 3
  • Head down deep breathing (HDDB) technique 4
• Pharmacologic Treatments:
  • Verapamil is considered the most effective currently available pharmacologic agent 3
  • Digitalis may be used for hemodynamically stable patients whose PSVTs are refractory to verapamil 3
  • Procainamide for patients with antegrade accessory pathway conduction and a history of atrial fibrillation 3
  • Adenosine for acute therapy in hemodynamically stable patients 5
  • Beta-blockers such as atenolol (though its use is cautioned in pregnancy due to teratogenic effects) 6
• Electrical Treatments:
  • Synchronized electrical countershock is the treatment of choice for hemodynamically unstable patients 3
  • Catheter ablation is safe, highly effective, and recommended as first-line therapy to prevent recurrence of PSVT 5
  • Emergent cardioversion for patients who are hemodynamically unstable 5, 6