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

Management of Recurrent PSVT

Catheter ablation is the first-line definitive therapy for recurrent symptomatic PSVT, with success rates of 94-98.5% and should be offered to all patients with recurrent episodes. 1, 2, 3

Acute Episode Management

When a patient presents with an acute PSVT episode, treatment depends on hemodynamic stability:

Hemodynamically Stable Patients

• Begin with vagal maneuvers (modified Valsalva maneuver, carotid sinus massage), which terminate approximately 25-43% of episodes 1, 4, 3
• If vagal maneuvers fail, administer adenosine 6 mg IV rapid push through a large vein followed by 20 mL saline flush, with 90-95% success rate 1, 4, 3
• If initial adenosine dose fails, give 12 mg IV rapid push 5
• Alternative agents if adenosine contraindicated or fails: IV diltiazem or verapamil (calcium channel blockers) are highly effective 5, 1, 4
• Beta blockers are reasonable but less effective than calcium channel blockers 1

Hemodynamically Unstable Patients

• Immediate synchronized cardioversion starting at 50-100 J (biphasic), increasing stepwise if initial shock fails 1, 4

Critical Caveat

Always rule out Wolff-Parkinson-White syndrome before administering AV nodal blocking agents (adenosine, calcium channel blockers, beta blockers, digoxin), as these can accelerate ventricular rate during atrial fibrillation and potentially cause ventricular fibrillation 1, 2, 4

Long-Term Management for Recurrent PSVT

First-Line: Catheter Ablation

Catheter ablation should be offered as first-line therapy for all patients with recurrent symptomatic PSVT, as it provides definitive cure without need for chronic medication 1, 2, 4, 3

• Success rates: 94.3-98.5% with single procedure 2, 3
• Low complication rates, including 1% risk of AV block for AVNRT 2
• Eliminates need for lifelong medication 2

Pharmacologic Options (When Ablation Declined or Not Feasible)

First-Line Oral Medications (Patients WITHOUT Pre-excitation)

Oral beta blockers, diltiazem, or verapamil are first-line pharmacologic options 1, 2, 4

• Beta blockers: atenolol, metoprolol tartrate, metoprolol succinate, nadolol, or propranolol 2
• Calcium channel blockers: diltiazem or verapamil 2
• Class I recommendation, Level B-R evidence 2

Second-Line Oral Medications

Flecainide or propafenone for patients without structural heart disease or ischemic heart disease 1, 2

• Propafenone 150 mg three times daily 2, 6
• Critical contraindication: Never use flecainide in patients with structural heart disease due to proarrhythmic risk 2, 7
• FDA-approved specifically for prevention of recurrent PSVT in patients without structural heart disease 6, 7

Third-Line Oral Medications

When first and second-line options fail or are contraindicated:

• Sotalol with careful QT monitoring 2
• Dofetilide 500 μg twice daily (50% probability of complete symptom suppression over 6 months) 2
• Amiodarone 200-400 mg daily maintenance dose, reserved for patients with structural heart disease when other options fail 2

Patient Education

Teach patients proper technique for vagal maneuvers (modified Valsalva maneuver) for self-management of acute episodes 1, 2

Special Populations

Pregnancy

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

Wolff-Parkinson-White Syndrome

• Synchronized cardioversion for hemodynamically unstable patients with pre-excited atrial fibrillation 1, 4
• Ibutilide or IV procainamide for stable patients with pre-excited atrial fibrillation 1, 4
• Absolutely avoid AV nodal blocking agents (adenosine, beta blockers, calcium channel blockers, digoxin) 1, 4

Common Pitfalls

• Adenosine may precipitate atrial fibrillation in 1-15% of patients, particularly problematic in those with ventricular pre-excitation 5
• Avoid adenosine in severe bronchial asthma 5
• Use extreme caution with concomitant IV calcium channel blockers and beta blockers due to potentiation of hypotensive/bradycardic effects 5
• Monitor for atrial or ventricular premature complexes after conversion, as they may trigger recurrence 5, 4