What is the management of Supraventricular Tachycardia (SVT)?

From the Guidelines

The management of Supraventricular Tachycardia (SVT) should prioritize vagal maneuvers, followed by pharmacological therapy with oral beta blockers, diltiazem, or verapamil, and consideration of electrophysiological (EP) study with the option of ablation for long-term management, as recommended by the 2015 ACC/AHA/HRS guideline 1. The initial approach to managing SVT involves attempting to terminate the arrhythmia using vagal maneuvers, such as the Valsalva maneuver or carotid sinus massage, which can be effective in up to 25% of cases 1. If vagal maneuvers are unsuccessful, pharmacological therapy can be initiated, with oral beta blockers, diltiazem, or verapamil being useful for ongoing management in patients with symptomatic SVT who do not have ventricular pre-excitation during sinus rhythm, as supported by the 2015 ACC/AHA/HRS guideline 1. Key considerations for the management of SVT include:

• Vagal maneuvers as the initial approach to terminate the arrhythmia
• Pharmacological therapy with oral beta blockers, diltiazem, or verapamil for ongoing management
• Electrophysiological (EP) study with the option of ablation for long-term management, particularly for patients with recurrent SVT or those who prefer a potentially curative treatment
• Patient education on how to perform vagal maneuvers for ongoing management of SVT, as recommended by the 2015 ACC/AHA/HRS guideline 1. In terms of specific pharmacological agents, the 2015 ACC/AHA/HRS guideline recommends the use of flecainide or propafenone as reasonable options for ongoing management in patients without structural heart disease or ischemic heart disease who have symptomatic SVT and are not candidates for, or prefer not to undergo, catheter ablation 1. However, it is essential to note that these agents have a risk of proarrhythmia in patients with structural heart disease or ischemic heart disease, and therefore should be used with caution in these patient populations, as highlighted in the guideline 1. Ultimately, the management of SVT should be individualized based on the patient's specific clinical presentation, medical history, and preferences, with the goal of improving symptoms, reducing the frequency and duration of episodes, and enhancing overall quality of life, as emphasized by the 2015 ACC/AHA/HRS guideline 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 management of Supraventricular Tachycardia (SVT) includes the use of flecainide acetate tablets for the prevention of paroxysmal supraventricular tachycardias (PSVT) in patients without structural heart disease.

• The use of flecainide acetate tablets should be reserved for patients in whom the benefits of treatment outweigh the risks.
• It is recommended to initiate treatment in a hospital setting for patients with sustained VT.
• The dosage schedule should be followed carefully to minimize the risk of proarrhythmic events. 2

From the Research

Management of Supraventricular Tachycardia (SVT)

The management of SVT can be categorized into several approaches, including nonpharmacologic, pharmacologic, and electrical treatments.

• Nonpharmacologic treatments aim to increase vagal tone and include techniques such as the Valsalva maneuver, carotid massage, and other vagal maneuvers 3.
• Pharmacologic treatments involve the use of medications such as verapamil, digitalis, and procainamide to convert the arrhythmia to a normal sinus rhythm 3.
• Electrical treatments, including synchronized electrical countershock, are typically reserved for hemodynamically unstable patients 3, 4.

Vagal Maneuvers

Vagal maneuvers are often recommended as the first-line treatment for stable patients with SVT.

• The Valsalva maneuver is a commonly used technique, although it has a relatively low cardioversion success rate 5.
• Modified Valsalva maneuvers have been developed to improve the efficacy of this technique, with some studies showing higher conversion rates to sinus rhythm 5, 6, 7.
• Other vagal maneuvers, such as carotid massage and the application of ice to the face, can also be effective in terminating SVT episodes 4, 3.

Comparison of Vagal Maneuvers

A network meta-analysis comparing the effectiveness of various vagal maneuvers for SVT found that the modified Valsalva maneuver was the most effective technique, with a higher conversion rate to sinus rhythm compared to carotid sinus massage and the standard Valsalva maneuver 6.

• The study also found that the adverse event rates amongst the different vagal maneuvers were similar, with a low certainty of evidence 6.

Treatment Approach

The treatment approach for SVT depends on the patient's hemodynamic stability.

• Hemodynamically unstable patients should be treated with electrical cardioversion 4, 3.
• Stable patients can be treated with vagal maneuvers or pharmacologic therapy, with the modified Valsalva maneuver being a recommended first-line treatment 6.