Acute Chest Pain in SVT Patient with Normal Sinus Rhythm
This patient requires immediate evaluation for acute coronary syndrome (ACS) and other life-threatening causes of chest pain, not SVT management, since the EKG shows normal sinus rhythm and the chest pain has already resolved. 1
Immediate Assessment Priority
The history of SVT is a red herring in this scenario. The patient is currently in normal sinus rhythm, meaning this is not an active SVT episode requiring cardioversion or adenosine. 2 The 4-hour duration of sharp left chest pain demands evaluation for:
- Acute coronary syndrome - Sharp chest pain lasting 4 hours in any adult warrants troponin measurement and serial EKGs regardless of SVT history 1
- Pulmonary embolism - Sharp chest pain with pleuritic features requires D-dimer or CT angiography based on Wells criteria 3
- Aortic dissection - Sharp chest pain requires blood pressure in both arms and consideration of CT angiography if risk factors present 3
- Pericarditis - Sharp positional chest pain may indicate pericardial inflammation requiring echocardiography 3
Why This Is Not SVT-Related
The American College of Cardiology notes that chest pain during SVT episodes occurs in hemodynamically unstable patients and is an indication for immediate cardioversion. 2 However, this patient's chest pain:
- Lasted 4 hours (SVT episodes typically terminate spontaneously or persist until treated) 2
- Has now resolved while in normal sinus rhythm 1
- Was not associated with documented tachycardia 1
Research demonstrates that in patients under 40 years with suspected SVT who also complain of chest pain, electrophysiological studies are generally negative (positive predictive value for negative EPS is 42% with chest pain alone). 4 This suggests chest pain in SVT patients often represents a separate pathology.
Critical Next Steps
Obtain immediately:
- Serial troponins at 0 and 3-6 hours to exclude myocardial infarction 3
- Repeat EKG to assess for dynamic ST-T wave changes 1
- Chest X-ray to evaluate for pneumothorax, pneumonia, or mediastinal widening 3
Do not:
- Attribute the chest pain to SVT simply because of the patient's history 4
- Discharge without excluding ACS in a patient with 4 hours of chest pain 3
- Start or adjust SVT medications when the patient is in normal sinus rhythm 3
SVT Evaluation Can Wait
Once life-threatening causes are excluded, then address the SVT history:
- The American College of Cardiology recommends obtaining transthoracic echocardiography in all patients with documented sustained SVT to exclude structural heart disease. 1
- Event or loop recorders are indicated for less frequent arrhythmias rather than daily Holter monitoring. 3
- Referral to cardiac electrophysiology is appropriate for documented sustained SVT, with catheter ablation having 94.3-98.5% single-procedure success rates. 1
Common Pitfall
The most dangerous error here is assuming the chest pain is SVT-related simply because of the patient's history. The American College of Cardiology specifically warns against dismissing chest pain during palpitations, as this combination warrants thorough cardiac evaluation. 3 The absence of MVP does not exclude other structural heart disease or coronary pathology. 1