What is the management of paroxysmal supraventricular tachycardia (PSVT)?

Management of Paroxysmal Supraventricular Tachycardia (PSVT)

Catheter ablation is the first-line therapy for recurrent symptomatic PSVT, with high success rates (94-98.5%) and low complication rates. 1, 2, 3

Acute Management Algorithm

Hemodynamically Unstable Patients

• Immediate synchronized cardioversion (50-100 J biphasic initially, with stepwise increase if needed) is recommended for patients with hemodynamically unstable PSVT 1

Hemodynamically Stable Patients

1. First-line: Vagal maneuvers

   • Valsalva maneuver and carotid sinus massage can terminate up to 25% of PSVTs 1, 4
   • Modified Valsalva maneuver has shown 43% effectiveness 3

2. Second-line: Adenosine

   • Initial dose: 6 mg IV rapid push through a large vein, followed by 20 mL saline flush 1
   • If ineffective, may increase to 12 mg IV, and repeat once if necessary 1
   • Highly effective with 91% termination rate 3
   • Contraindicated in patients with known Wolff-Parkinson-White syndrome with pre-excitation 2

3. Third-line: Calcium channel blockers or beta blockers

   • Intravenous diltiazem or verapamil for hemodynamically stable patients 1
   • Beta blockers are reasonable but less effective than diltiazem 1
   • CAUTION: AV nodal blocking agents (adenosine, beta blockers, calcium channel blockers, digoxin) should be avoided in patients with WPW syndrome and pre-excitation 1, 2

Long-Term Management Options

Definitive Treatment

• Catheter ablation is recommended as first-line therapy for recurrent symptomatic PSVT 1, 2, 3
  • Success rates of 94.3-98.5% with low complication rates (1% risk of AV block for AVNRT) 2, 3
  • Provides definitive cure without need for chronic medication 2

Pharmacological Options

1. First-line medications

   • Beta blockers (atenolol, metoprolol, nadolol, propranolol) 2
   • Calcium channel blockers (diltiazem, verapamil) 2

2. Second-line medications

   • Flecainide - indicated for prevention of PSVT in patients without structural heart disease 5
   • Propafenone - shown to be effective in clinical trials with 47-67% of patients remaining attack-free compared to 7-22% with placebo 6, 2
   • CAUTION: Flecainide should never be used in patients with structural heart disease due to proarrhythmic risk 2, 5

3. Third-line medications

   • Sotalol - for patients who are not candidates for catheter ablation 2
   • Dofetilide - when other medications are ineffective or contraindicated 2
   • Amiodarone - reserved for when other medications are ineffective or contraindicated 2
   • Digoxin - less commonly used due to availability of more effective options 2

Special Considerations

Wolff-Parkinson-White (WPW) Syndrome

• Always rule out pre-excitation before starting calcium channel blockers 2
• For pre-excited AF in WPW syndrome:
  • Synchronized cardioversion for hemodynamically unstable patients 1
  • Ibutilide or intravenous procainamide for hemodynamically stable patients 1

Pregnancy

• Preferred medications include metoprolol, propranolol, digoxin, flecainide, propafenone, sotalol, and verapamil 2

Patient Education

• Teach patients proper technique for performing vagal maneuvers for self-management of PSVT episodes 1, 2
• Inform patients about potential complications of untreated PSVT, including tachycardia-mediated cardiomyopathy (rare, 1%) 3

Common Symptoms of PSVT

• Palpitations (86%), chest discomfort (47%), dyspnea (38%) 3
• Other symptoms may include fatigue, lightheadedness, presyncope, or syncope 7
• Polyuria may occur during episodes due to release of atrial natriuretic peptide 7