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) can be effective, as well as beta-blockers such as metoprolol (5 mg IV) as alternatives. Some key points to consider in the treatment of PSVT include:

• Vagal maneuvers are the initial treatment of choice, with a success rate of up to 25% 1
• Adenosine is the first-line medication for PSVT, with a high success rate and few side effects 1
• Calcium channel blockers and beta-blockers are effective alternatives for patients with recurrent episodes 1
• Catheter ablation offers a definitive treatment with success rates exceeding 90% and should be considered for patients with frequent episodes or medication intolerance 1 The treatment of PSVT aims to interrupt the abnormal electrical conduction pathways in the heart, effectively terminating the arrhythmia and restoring normal sinus rhythm. In terms of long-term management, oral medications including beta-blockers, calcium channel blockers, or antiarrhythmics like flecainide may be prescribed, with the choice of medication depending on the individual patient's needs and medical history 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 first-line recommended treatment for stable PSVT is the use of vagal maneuvers, such as the Valsalva maneuver 3 and the modified Valsalva maneuver 4, 5.
• Other nonpharmacologic treatments include carotid sinus massage, head-down tilt, activation of the diving reflex, and use of the pneumatic antishock garment 6.
• Pharmacologic agents, such as verapamil 6, 7, digitalis 6, and procainamide 6, may be used to treat PSVT, especially in patients who are refractory to vagal maneuvers.
• Synchronized electrical countershock is the treatment of choice for hemodynamically unstable patients 6, 5.
• Catheter ablation is a highly effective treatment option for preventing recurrence of PSVT, with success rates of 94.3% to 98.5% 5.

Vagal Maneuvers

• The modified Valsalva maneuver is the most effective vagal maneuver for converting PSVT to sinus rhythm, with a high surface under the cumulative ranking curve analysis (SUCRA) value 4.
• The standard Valsalva maneuver and carotid sinus massage are also effective, but to a lesser extent 4.
• Vagal maneuvers are safe in young, otherwise healthy patients, but may be problematic in older patients with coronary or cerebrovascular disease 7.

Pharmacotherapy

• Verapamil is a commonly used pharmacologic agent for treating PSVT, with a high conversion rate 6, 7.
• Digitalis and procainamide may also be used, especially in patients with certain types of PSVT, such as Wolff-Parkinson-White syndrome 6.
• Long-term pharmacotherapy may be used to prevent recurrence of PSVT, but the evidence is limited 5.