In a patient with chronic obstructive pulmonary disease (COPD) who has paroxysmal supraventricular tachycardia (PSVT), how should the acute episode be treated and what are the preferred long‑term management strategies?

Management of PSVT in a Patient with COPD

In a COPD patient experiencing PSVT, adenosine is the first-line acute treatment after vagal maneuvers, with IV diltiazem or verapamil as alternatives; avoid beta-blockers due to bronchospasm risk, and consider catheter ablation for definitive long-term management rather than chronic pharmacotherapy.

Acute Management of PSVT in COPD

Initial Stabilization and Diagnosis

• Immediately assess hemodynamic stability—if the patient is hypotensive, altered, or in shock, proceed directly to synchronized electrical cardioversion 1, 2, 3.
• Obtain a 12-lead ECG to confirm narrow-complex tachycardia (QRS <120 ms) and distinguish PSVT from ventricular tachycardia, which can masquerade as supraventricular rhythm 4.
• Ensure continuous cardiac monitoring, frequent blood pressure measurement, and readily available defibrillator and emergency equipment 1.

Vagal Maneuvers

• Attempt the modified Valsalva maneuver first in hemodynamically stable patients, as it terminates PSVT in 43% of cases and is safer than carotid massage, especially in elderly patients 2, 3, 4.
• Alternative vagal techniques include head-down tilt or activation of the diving reflex if Valsalva fails 3.

Pharmacologic Therapy

First-line: Adenosine

• Administer IV adenosine 6 mg rapid bolus; if no response within 1–2 minutes, give 12 mg, and repeat 12 mg once more if needed 2, 4, 5, 6.
• Adenosine terminates PSVT in 91–93% of patients when dosed up to 12 mg, with an average conversion time of 30 seconds 2, 6.
• Adenosine is preferred in COPD because it does not cause bronchospasm and has a half-life of less than 10 seconds, making adverse effects (flushing, chest discomfort, dyspnea) transient and lasting under 1 minute 6.
• Caution: Adenosine may precipitate transient bronchospasm in severe asthma, but COPD is not an absolute contraindication; monitor closely 4.

Second-line: Calcium Channel Blockers

• If adenosine fails or is contraindicated, use IV diltiazem as the preferred calcium channel blocker in COPD 1, 5.
• Diltiazem dosing: 0.25 mg/kg (typically 20 mg) IV bolus over 2 minutes; if PSVT persists after 15 minutes, give a second bolus of 0.35 mg/kg (typically 25 mg) 1.
• Diltiazem converts PSVT to sinus rhythm in 88% of patients within 3 minutes of the first or second bolus 1.
• Verapamil (5 mg IV, repeat 7.5 mg if needed) is an alternative with 91% efficacy, but diltiazem is often preferred due to less negative inotropy 3, 5, 6.
• Critical pitfall: Use calcium channel blockers with extreme caution if the patient is on beta-blockers, has heart failure, or is hemodynamically compromised, as they reduce myocardial contractility and can precipitate hypotension 1.

Avoid Beta-Blockers

• Do not use beta-blockers (e.g., metoprolol, esmolol) in COPD patients with PSVT, as they cause bronchospasm and worsen airflow obstruction 7.

Electrical Cardioversion

• Perform synchronized electrical cardioversion immediately if the patient is hemodynamically unstable (hypotension, altered mental status, chest pain, heart failure) or if pharmacologic therapy fails 1, 2, 3, 4.

Long-Term Management and Prevention

Catheter Ablation (Preferred)

• Catheter ablation is the first-line therapy to prevent recurrent PSVT, with single-procedure success rates of 94–98% 2.
• Ablation is particularly advantageous in COPD patients because it eliminates the need for chronic pharmacotherapy that may interact with COPD medications or exacerbate respiratory symptoms 2.
• Refer all patients with symptomatic, recurrent PSVT for electrophysiology evaluation and ablation 2, 4, 5.

Chronic Pharmacotherapy (Second-line)

• If the patient declines ablation or is not a candidate, consider calcium channel blockers (diltiazem or verapamil) or digoxin for long-term suppression 2, 3, 5.
• Avoid beta-blockers for chronic PSVT prevention in COPD due to bronchospasm risk 7.
• Evidence for long-term pharmacotherapy efficacy is limited compared to ablation 2.

Special Considerations in COPD

Drug Interactions and Respiratory Effects

• Theophylline/aminophylline (often used in severe COPD) can reduce adenosine efficacy by competitive antagonism; higher adenosine doses (up to 12 mg) may be required 4, 6.
• Conversely, dipyridamole (rarely used) potentiates adenosine and may require dose reduction 4.
• Calcium channel blockers do not cause bronchospasm and are safe in COPD, but monitor for hypotension, especially if the patient is on diuretics or has concurrent heart failure 1, 5.

COPD Exacerbation Considerations

• If the patient is experiencing a concurrent COPD exacerbation, continue standard exacerbation management (short-acting bronchodilators, systemic corticosteroids, antibiotics if indicated) while treating PSVT 7.
• Do not delay PSVT treatment to address the exacerbation; PSVT itself can worsen dyspnea and precipitate respiratory decompensation 2, 5.
• Ensure controlled oxygen delivery targeting SpO₂ 88–92% to avoid CO₂ retention, and obtain arterial blood gas within 60 minutes if hypercapnia is suspected 7.

Wolff-Parkinson-White (WPW) Syndrome

• Do not use adenosine, diltiazem, verapamil, or digoxin if WPW syndrome with atrial fibrillation is suspected (wide-complex irregular tachycardia), as these agents can accelerate ventricular rate via the accessory pathway 1, 3, 4.
• In WPW with atrial fibrillation, use IV procainamide if hemodynamically stable or immediate cardioversion if unstable 3.

Common Pitfalls to Avoid

• Do not assume all narrow-complex tachycardias are PSVT—always obtain a 12-lead ECG to exclude ventricular tachycardia with aberrancy 4.
• Do not use beta-blockers in COPD patients with PSVT, as bronchospasm can be life-threatening 7.
• Do not use calcium channel blockers in hemodynamically unstable patients or those with severe heart failure without immediate cardioversion capability 1.
• Do not delay cardioversion in unstable patients while attempting pharmacologic therapy 1, 2, 3.
• Do not discharge patients with recurrent PSVT without arranging electrophysiology referral for ablation, as this is curative and avoids long-term medication risks 2, 5.