What are the treatment options for symptoms of tachycardia?

Treatment Options for Symptoms of Tachycardia

The first-line treatments for symptomatic tachycardia include vagal maneuvers, adenosine, and synchronized cardioversion for hemodynamically unstable patients, while beta blockers, calcium channel blockers, and other antiarrhythmic medications are recommended for ongoing management based on the specific type of tachycardia. 1, 2

Common Symptoms of Tachycardia

Patients with tachycardia typically present with:

• Palpitations (most common symptom) 1
• Chest discomfort or pain 1
• Fatigue and shortness of breath 1
• Light-headedness and dizziness 1
• Anxiety 1
• Dyspnea 1
• Syncope (uncommon but concerning) 1

Acute Management of Tachycardia

Hemodynamically Unstable Patients

• Synchronized cardioversion is the treatment of choice for patients with hemodynamically unstable tachycardia (altered mental status, hypotension, shock, acute heart failure) 1
• Should be performed promptly when vagal maneuvers and adenosine fail or aren't feasible 1

Hemodynamically Stable Patients

1. Vagal maneuvers (first-line):

   • Valsalva maneuver (bearing down against closed glottis for 10-30 seconds) 1
   • Carotid sinus massage (after confirming absence of bruits) 1
   • Application of cold towel to face 1

2. Adenosine (if vagal maneuvers fail):

   • First-line pharmacological treatment for SVT 1, 2
   • Terminates approximately 95% of AVNRT cases 1
   • Also useful diagnostically to unmask atrial activity in arrhythmias 1

3. Intravenous beta blockers, diltiazem, or verapamil:

   • Reasonable for acute treatment in hemodynamically stable patients 1, 2
   • Particularly effective for converting AVNRT to sinus rhythm 1
   • Should be avoided in patients with suspected VT, pre-excited AF, systolic heart failure 1

Long-Term Management Options

Pharmacological Therapy

1. Beta blockers:

   • First-line for ongoing management of symptomatic SVT 2
   • Metoprolol is cardioselective (primarily affects beta-1 receptors in the heart) 3
   • Reduces heart rate, cardiac output, and oxygen requirements of the heart 3
   • Caution in patients with heart failure, bronchospastic disease, or diabetes 3

2. Calcium channel blockers:

   • Non-dihydropyridine agents (diltiazem, verapamil) are effective for rate control 1, 2
   • Particularly useful for AVNRT 1
   • Avoid in patients with heart failure or suspected ventricular tachycardia 1

3. Other antiarrhythmics:

   • Amiodarone may be considered in certain cases 1
   • Flecainide and propafenone for specific types of SVT 1
   • Sotalol for hemodynamically stable monomorphic ventricular tachycardia 1

Definitive Treatment

• Catheter ablation is considered definitive treatment for recurrent SVT 2
• Recommended for patients with frequent or poorly tolerated episodes 2
• High success rates with low complication rates 4

Treatment Based on Specific Tachycardia Types

Supraventricular Tachycardia (SVT)

• First-line: Vagal maneuvers, adenosine 1, 2
• Second-line: IV beta blockers, diltiazem, or verapamil 1
• Long-term: Oral beta blockers, calcium channel blockers, or catheter ablation 2

Atrial Fibrillation

• Hemodynamically unstable: Immediate electrical cardioversion 1
• Rate control: Beta blockers and diltiazem are drugs of choice 1
• Rhythm control: Ibutilide, dofetilide, flecainide, or amiodarone 1

Wide-Complex Tachycardia

• Hemodynamically unstable: Immediate electrical cardioversion 1
• Stable monomorphic VT: Procainamide or amiodarone 1
• Polymorphic VT with long QT: IV magnesium, pacing, beta blockers 1

Special Considerations

• Pregnancy: Many antiarrhythmics should be avoided during pregnancy 1
• Heart failure: Avoid calcium channel blockers; amiodarone may be used 1
• Wolff-Parkinson-White syndrome: Avoid AV nodal blocking agents; expedient referral to cardiology 4
• Autonomic hyperreactivity (amphetamine/cocaine): Benzodiazepines first, then phentolamine, nicardipine, or nitroprusside 1

Potential Complications of Untreated Tachycardia

• Heart failure and pulmonary edema 1
• Myocardial ischemia 1
• Tachycardia-induced cardiomyopathy (potentially reversible but requires careful follow-up) 5
• In adults with congenital heart disease: increased risk of heart failure, stroke, and sudden cardiac death 1