From the Guidelines
The management of supraventricular tachycardia (SVT) should prioritize a stepwise approach, starting with vagal maneuvers and considering pharmacological therapy with oral beta blockers, diltiazem, or verapamil for ongoing management in patients with symptomatic SVT who do not have ventricular pre-excitation during sinus rhythm, as recommended by the 2015 ACC/AHA/HRS guideline 1.
Key Recommendations
- Vagal maneuvers, such as the Valsalva maneuver, should be the initial step in managing SVT, as they can potentially terminate the arrhythmia 1.
- For patients with symptomatic SVT, oral beta blockers, diltiazem, or verapamil are useful for ongoing management, with a dosage of verapamil up to 480 mg/day, as supported by randomized controlled trials (RCTs) 1.
- Electrophysiological (EP) study with the option of ablation is a useful diagnostic and potential treatment approach for SVT, offering a high success rate for both AVNRT and AVRT, with low frequency of serious complications 1.
- Flecainide or propafenone may be considered for ongoing management in 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, with a dosage of propafenone ranging from 450 mg/day to 900 mg/day and flecainide from 100 mg/day to 300 mg/day 1.
Considerations
- The choice of management strategy depends on the specific SVT mechanism, patient characteristics, and hemodynamic stability, with the goal of terminating the acute episode and preventing recurrences while minimizing side effects.
- Patients should be educated on how to perform vagal maneuvers for ongoing management of SVT, which can help avoid prolonged tachycardia episodes and reduce the need for medical attention 1.
- The 2015 ACC/AHA/HRS guideline provides a comprehensive framework for the management of adult patients with supraventricular tachycardia, emphasizing the importance of individualized treatment approaches 1.
From the FDA Drug Label
In patients without structural heart disease, flecainide acetate tablets, USP are indicated for the prevention of: •paroxysmal supraventricular tachycardias (PSVT), including atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia and other supraventricular tachycardias of unspecified mechanism associated with disabling symptoms Flecainide acetate tablets, USP are also indicated for the prevention of: •Documented ventricular arrhythmias, such as sustained ventricular tachycardia (sustained VT), that in the judgment of the physician are life-threatening
The management of SVT with flecainide involves the prevention of paroxysmal supraventricular tachycardias (PSVT) in patients without structural heart disease.
- Flecainide acetate tablets are indicated for this purpose, specifically for PSVT associated with disabling symptoms.
- The use of flecainide acetate should be reserved for patients in whom the benefits of treatment outweigh the risks, due to its potential proarrhythmic effects 2.
- It is essential to follow the recommended dosage schedule and monitor patients carefully, especially those with underlying heart disease, as the incidence of proarrhythmic events can be high 2.
From the Research
Management of Supraventricular Tachycardia (SVT)
Diagnosis and Treatment
The management of SVT involves both non-pharmacological and pharmacological interventions. According to 3, vagal maneuvers may terminate the arrhythmia, and if this fails, adenosine is effective in the acute setting. Calcium channel blockers (diltiazem or verapamil) or beta blockers (metoprolol) can be used acutely or as long-term therapy.
Vagal Maneuvers
Vagal maneuvers, such as the Valsalva maneuver and carotid sinus massage, are often used as the initial treatment for SVT. Studies have shown that these maneuvers can be effective in terminating SVT, with success rates ranging from 10.5% to 19.4% 4. However, there is no significant difference in efficacy between the Valsalva maneuver and carotid sinus massage 4.
Pharmacological Treatment
If vagal maneuvers are unsuccessful, pharmacological treatment may be necessary. Adenosine is often used as the first-line treatment for SVT, but it can cause minor adverse events such as nausea, chest tightness, and shortness of breath 5. Calcium channel antagonists, such as verapamil, are also effective in treating SVT, but they can cause hypotension 5.
Catheter Ablation
Catheter ablation is a highly effective treatment for SVT, with a success rate of 95% and a recurrence rate of less than 5% 3. This procedure involves the use of radiofrequency energy to destroy the abnormal electrical pathways in the heart that are causing the arrhythmia.
Current Trends
Current trends in SVT management emphasize the importance of understanding the mechanisms and classifications of different SVTs in determining management at the bedside and in the electrophysiology laboratory 6. Newer techniques, such as cryoablation, are being investigated as alternative forms of energy delivery, but their long-term effectiveness is still limited 6.
Key Points
- Vagal maneuvers, such as the Valsalva maneuver and carotid sinus massage, can be effective in terminating SVT.
- Adenosine and calcium channel antagonists are effective pharmacological treatments for SVT, but they can cause adverse events.
- Catheter ablation is a highly effective treatment for SVT, with a high success rate and low recurrence rate.
- Understanding the mechanisms and classifications of different SVTs is important in determining management at the bedside and in the electrophysiology laboratory.