What is the management approach for a patient with a history of type 2 diabetes or obesity, taking Semaglutide (GLP-1 receptor agonist), who develops supraventricular tachycardia (SVT)?

Management of Supraventricular Tachycardia in Patients Taking Semaglutide

Continue semaglutide therapy while managing the SVT through standard cardiac protocols, as there is no established causal relationship between GLP-1 receptor agonists and supraventricular arrhythmias, and semaglutide provides substantial cardiovascular benefits that should not be interrupted without compelling evidence of harm. 1

Immediate SVT Management

• Treat the SVT according to standard ACLS protocols (vagal maneuvers, adenosine, cardioversion as indicated), independent of semaglutide use 1
• Assess for underlying triggers including electrolyte disturbances (particularly if the patient has experienced significant gastrointestinal side effects leading to dehydration), thyroid dysfunction, or concurrent stimulant use 1
• Check serum potassium, magnesium, and calcium levels, as GLP-1 receptor agonists can cause gastrointestinal effects (nausea in 17-44% of patients, vomiting in 7-25%, diarrhea in 12-32%) that may lead to electrolyte depletion 1

Cardiovascular Context and Semaglutide Benefits

• Semaglutide demonstrates significant cardiovascular protection, reducing the composite incidence of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke by 20-26% (HR 0.74-0.80) in patients with established cardiovascular disease 1, 2
• In patients with obesity-related heart failure with preserved ejection fraction (HFpEF), semaglutide improved cardiac remodeling by attenuating left atrial volume progression (estimated mean difference -6.13 mL; P = 0.0013) and reducing right ventricular enlargement 3
• Semaglutide improved diastolic function parameters including E-wave velocity (EMD: -5.63 cm/s; P = 0.0037) and E/A ratio (EMD: -0.14; P = 0.0075) 3

Atrial Fibrillation Evidence (Most Relevant to SVT)

• In the STEP-HFpEF Program, 45% of participants had a history of atrial fibrillation (40% paroxysmal, 24% persistent, 35% permanent) 2
• Semaglutide led to larger improvements in heart failure symptoms and physical limitations in participants WITH atrial fibrillation compared to those without AF (KCCQ-CSS improvement 11.5 points vs 4.3 points; P interaction = 0.001) 2
• There were fewer serious adverse events and serious cardiac disorders in participants treated with semaglutide versus placebo, irrespective of AF history 2
• Semaglutide consistently reduced NT-proBNP and inflammatory markers (C-reactive protein) regardless of AF status 2

Specific Evaluation for This Patient

• Obtain baseline ECG to document SVT type and assess for structural heart disease 1
• Perform echocardiography if not recently done, particularly to assess for left atrial enlargement, valvular disease, or HFpEF 3
• Check thyroid function (TSH, free T4), as semaglutide is contraindicated in patients with personal or family history of medullary thyroid cancer or MEN2, but does not directly cause thyroid dysfunction leading to arrhythmias 1
• Review concomitant medications for pro-arrhythmic agents or drug interactions 1

Decision Algorithm for Semaglutide Continuation

Continue semaglutide if:

• SVT is controlled with standard cardiac management 1, 2
• No evidence of medication-induced electrolyte disturbances that cannot be corrected 1
• Patient has diabetes, obesity, or established cardiovascular disease (where cardiovascular benefits are proven) 1, 2
• No alternative explanation for SVT is identified 2

Consider temporary hold only if:

• Severe, refractory gastrointestinal side effects are causing significant dehydration and electrolyte depletion that cannot be managed 1
• Patient requires urgent surgery with anesthesia (hold for 3 weeks due to aspiration risk from delayed gastric emptying, not cardiac concerns) 1

Do NOT discontinue semaglutide based on:

• SVT occurrence alone, as there is no established causal relationship 2
• Presence of atrial fibrillation or other supraventricular arrhythmias, as evidence suggests potential benefit rather than harm 2

Ongoing Monitoring

• Monitor electrolytes closely during the first 3 months of semaglutide therapy, particularly if gastrointestinal side effects are prominent 1
• Assess cardiac rhythm at follow-up visits (every 3-6 months after reaching maintenance dose) 1
• Monitor NT-proBNP levels if the patient has heart failure, as semaglutide reduces these levels over time 2, 4
• Ensure adequate hydration and electrolyte replacement if gastrointestinal side effects persist 1

Critical Pitfall to Avoid

• Do not reflexively discontinue semaglutide upon SVT diagnosis without thorough evaluation, as this removes proven cardiovascular benefits (20-26% reduction in major adverse cardiovascular events) in a population that may benefit most 1, 2
• The evidence from the STEP-HFpEF trials demonstrates that semaglutide is safe and potentially beneficial in patients with atrial arrhythmias, with fewer serious cardiac adverse events compared to placebo 2