From the Guidelines
For the management of supraventricular tachycardia (SVT), I strongly recommend starting with vagal maneuvers, followed by pharmacological therapy with oral beta blockers, diltiazem, or verapamil, and considering electrophysiological (EP) study with the option of ablation for definitive treatment, as supported by the 2015 ACC/AHA/HRS guideline 1.
Initial Management
The initial approach to managing SVT should include vagal maneuvers such as the Valsalva maneuver or the application of an ice-cold, wet towel to the face, as these can effectively terminate SVT episodes 1.
- Vagal maneuvers are recommended for ongoing management of SVT, as they can help avoid prolonged tachycardia episodes and reduce the need for medical attention.
- Patient education on performing vagal maneuvers is crucial, as it empowers patients to manage their condition more effectively.
Pharmacological Therapy
For patients with symptomatic SVT who do not have ventricular pre-excitation during sinus rhythm, oral beta blockers, diltiazem, or verapamil are recommended for ongoing management, as they have been shown to reduce SVT episode frequency and duration 1.
- These medications can be used for long-term prophylactic therapy, especially in patients who prefer not to undergo ablation or do not have access to a cardiac electrophysiologist.
- The choice of medication should be based on patient preferences, potential side effects, and comorbid conditions.
Electrophysiological Study and Ablation
Electrophysiological (EP) study with the option of ablation is a highly effective treatment for SVT, offering the potential for definitive cure without the need for chronic pharmacological therapy, as highlighted in the 2015 ACC/AHA/HRS guideline 1.
- EP study and ablation should be considered as first-line therapy for symptomatic SVT, especially in patients with recurrent episodes or those who prefer a more definitive treatment approach.
- The success rates for ablation of both AVNRT and AVRT are high, with low frequencies of potentially serious complications, making it a favorable option for many patients.
Additional Considerations
For 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, flecainide or propafenone may be considered for ongoing management, as they have been shown to be effective in preventing recurrences of SVT 1.
- However, these medications should be used with caution, as they carry a risk of proarrhythmia in patients with structural heart disease or ischemic heart disease.
From the FDA Drug Label
Verapamil inhibits the calcium ion (and possibly sodium ion) influx through slow channels into conductile and contractile myocardial cells and vascular smooth muscle cells. The antiarrhythmic effect of verapamil appears to be due to its effect on the slow channel in cells of the cardiac conduction system... By interrupting reentry at the AV node, verapamil can restore normal sinus rhythm in patients with paroxysmal supraventricular tachycardias (PSVT), including PSVT associated with Wolff-Parkinson-White syndrome.
Management of SVT: Verapamil (IV) can be used to restore normal sinus rhythm in patients with paroxysmal supraventricular tachycardias (PSVT) by interrupting reentry at the AV node 2.
- Key points:
- Verapamil inhibits calcium ion influx through slow channels in the cardiac conduction system
- It can restore normal sinus rhythm in patients with PSVT
- Peak therapeutic effects occur within 3 to 5 minutes after a bolus injection
- Note: Flecainide (PO) is also indicated for the prevention of paroxysmal supraventricular tachycardias (PSVT), but the provided text does not describe its use for acute management of SVT 3.
From the Research
Management of Supraventricular Tachycardia (SVT)
The management of SVT involves both acute and long-term strategies.
- Acute management includes:
- Vagal maneuvers, such as the modified Valsalva maneuver, which can be effective in terminating the arrhythmia 4, 5, 6
- Adenosine, which is effective in the acute setting 4, 5
- Calcium channel blockers (diltiazem or verapamil) or beta blockers (metoprolol) can be used acutely or as long-term therapy 4, 6
- Long-term management includes:
- Class Ic antiarrhythmics (flecainide or propafenone) can be used long-term 4
- Class Ia antiarrhythmics (quinidine, procainamide, or disopyramide) are used less often due to their modest effectiveness and adverse effects 4
- Class III antiarrhythmics (amiodarone, sotalol, or dofetilide) are effective but have potential adverse effects and should be administered in consultation with a cardiologist 4
- Catheter ablation, which has a success rate of 95% and recurrence rate of less than 5%, and is the preferred treatment for symptomatic patients with Wolff-Parkinson-White syndrome 4, 5, 6
Treatment Options
Treatment options for SVT depend on several factors, including frequency of symptoms, risk stratification, and patient preference 6, 7.
- Catheter ablation is a curative option for many patients and is recommended as first-line therapy to prevent recurrence of PSVT 5, 6
- Pharmacotherapy, including calcium channel blockers, β-blockers, and antiarrhythmic agents, is an important component of acute and long-term management of PSVT 5, 6
- All patients treated for SVT should be referred for a heart rhythm specialist opinion 6
Guidelines and Recommendations
The European Society of Cardiology guidelines continue to advocate for the use of vagal maneuvers and adenosine as first-line therapies in the acute diagnosis and management of SVT 6, 7.
- The 2019 European Society of Cardiology Guidelines provide a comprehensive overview of current developments in the field and recommendations for the management of adults with SVT 7
- A review of the techniques used to differentiate the mechanisms of SVT highlights the importance of scrutinizing electrocardiograms and analyzing the onset of tachycardia, mode of tachycardia termination, and effects of premature ventricular contractions, premature atrial contractions, and aberrancy during tachycardia 8