Should a patient over 67 with Paroxysmal Supraventricular Tachycardia (PSVT) undergo Electrophysiology Study (EPS) with Radiofrequency Ablation (RFA)?

Management of PSVT in Patients Over 67 Years: EPS with RFA Recommendation

For patients over 67 years with symptomatic Paroxysmal Supraventricular Tachycardia (PSVT), electrophysiology study (EPS) with radiofrequency ablation (RFA) is strongly recommended as the definitive treatment due to its high success rate and favorable safety profile, even in older populations.

Rationale for EPS with RFA in Older Patients

• EPS with RFA is considered the definitive treatment for PSVT, providing precise diagnosis of the underlying arrhythmia mechanism and localization of the site of origin while simultaneously offering curative treatment 1
• Studies have shown that catheter ablation has success rates of 94.3% to 98.5% in treating PSVT, making it the most effective therapy to prevent recurrence 2
• Despite concerns about age, ablation outcomes in older patients (>75 years) have been shown to be similar to those in younger patients, with success rates of 98.7% in patients over 75 years comparable to 98.7-98.8% in younger age groups 1
• Complication rates remain low in older patients, with hemodynamically stable pericardial effusion observed in only 0.8% of patients over 75 years, and no pacemakers needed in this age group 1

Alternatives to Consider if EPS/RFA is Declined

If a patient is not a candidate for or prefers not to undergo catheter ablation, pharmacological options include:

• Beta blockers or non-dihydropyridine calcium channel blockers (diltiazem, verapamil) as first-line agents for ongoing management of symptomatic PSVT 1, 3
• Flecainide or propafenone may be reasonable for ongoing management in patients without structural heart disease or ischemic heart disease 1
• Sotalol may be considered as an alternative option for ongoing management in patients with symptomatic PSVT 1
• Dofetilide may be reasonable when other medications are ineffective or contraindicated 1
• Amiodarone should only be considered when other options have failed due to its potential long-term toxicity 1

Cost-Effectiveness Considerations

• A rigorous cost-effectiveness Markov model comparing radiofrequency ablation to medical management concluded that for symptomatic patients with monthly episodes of PSVT, radiofrequency ablation was both more effective and less expensive than long-term medical therapy 1
• This economic advantage, combined with the clinical benefits, further supports EPS with RFA as the preferred approach 1

Important Considerations for Older Patients

• Older patients with PSVT often have more comorbid medical conditions, higher incidence of structural or ischemic heart disease, and more severe symptoms associated with SVT 1
• While complications may be slightly higher in older patients compared to younger ones, the overall complication rates remain low and acceptable 1
• The decision between ablation and pharmacological therapy should be made after carefully weighing the risks and benefits of each approach, with consideration of the patient's specific clinical situation 1

Practical Approach to Management

1. Confirm the diagnosis of PSVT with appropriate documentation (ECG during an arrhythmic event or ambulatory monitoring) 2
2. Assess for structural heart disease which may influence treatment options 1
3. For acute management of PSVT episodes, teach the patient vagal maneuvers (modified Valsalva maneuver has 43% effectiveness) 2
4. For definitive treatment, refer for EPS with RFA as the first-line therapy, which has the highest success rate and is cost-effective 1, 2
5. If the patient declines EPS with RFA, select appropriate pharmacological therapy based on the absence or presence of structural heart disease 1

Common Pitfalls to Avoid

• Delaying referral for EPS with RFA in favor of long-term pharmacological therapy, which is less effective and potentially more costly in the long run 1
• Overlooking the possibility of tachycardia-mediated cardiomyopathy (occurs in approximately 1% of PSVT patients) which can be prevented with definitive treatment 2
• Assuming older age alone is a contraindication to EPS with RFA, when evidence shows good outcomes in elderly patients 1
• Using amiodarone as an early treatment option rather than as a last resort, given its potential for long-term toxicity 1