Supraventricular Tachycardia Management in the Adult

Aka: Supraventricular Tachycardia Management in the Adult, Narrow Complex Tachycardia in the Adult, Supraventricular Tachycardia in the Adult, Paroxysmal Supraventricular Tachycardia in the Adult, PSVT in the Adult, Supraventricular Tachycardia in Pregnancy

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II. Approach: Step 1 - Is patient unstable

  1. Criteria
    1. Altered Mental Status
    2. Chest Pain persistent
    3. Hypotension
  2. Management
    1. Stable
      1. Go to Step 2
    2. Unstable:
      1. Go to Unstable Tachycardia for Synchronized Cardioversion

III. Approach: Step 2 - Regular or Irregular Narrow Complex Tachycardia

  1. Regular Narrow Complex Tachycardia
    1. Vagal Maneuvers
    2. Valsalva Maneuver
      1. See Valsalva for positional modifications (increased efficacy)
    3. Adenosine 6 mg IV (may repeat at 12 mg IV)
      1. Some patients may prefer Diltiazem to the brief adverse Sensation to Adenosine
        1. However, Diltiazem risks Hypotension, whereas Adenosine effects are transient
      2. Adenosine and Diltiazem are similarly effective
        1. Alabed (2017) Cochrane Database Syst Rev 10: CD005154 +PMID:29025197 [PubMed]
    4. Go to Step 3 below
  2. Irregular Narrow Complex Tachycardia
    1. Causes
      1. Atrial Fibrillation (most likely)
      2. Atrial Flutter
      3. Multifocal Atrial Tachycardia
    2. Management
      1. See Atrial Fibrillation with Rapid Ventricular Response
      2. Consider Consultation with cardiology
      3. Avoid Adenosine in irregular Narrow Complex Tachycardia (due to risk of Ventricular Fibrillation)
      4. Consider Synchronized Cardioversion if known onset
      5. Rate control
        1. Diltiazem
          1. Protocol 1
            1. Bolus 1: 20 mg (0.25 mg/kg) IV bolus over 2 min
            2. Bolus 2: 25 mg (0.35 mg/kg) IV bolus over 2 min (if indicated, at least 15 min after first)
            3. Drip: 10 mg/hour (typical range: 5-15 mg/hour)
          2. Protocol 2
            1. Diltiazem 2.5 mg/min titrated slowly to a maximum of 50 mg/min
            2. Cardioversion by 12 mg in 50% and 18 mg in 75%
              1. Lim (2009) Resuscitation 80(5): 523-8 [PubMed]
        2. Metoprolol (Lopressor)
          1. Avoid in acute CHF or COPD exacerbation
          2. Bolus: 2.5 to 5 mg IV every 2-5 min (maximum 15 mg in 15 min)

IV. Approach: Step 3 - Regular Narrow Complex Tachycardia

  1. Rhythm converts with basic measures in step 2 (Vagal Maneuvers and Adenosine)
    1. Suggests Reentry Supraventricular Tachycardia
    2. Recurrence management
      1. Adenosine or
      2. AV nodal blocking agent (e.g, Diltiazem, Beta Blocker)
        1. See Diltiazem and Metoprolol dosing under rate control above
  2. Rhythm does not convert
    1. Causes
      1. Atrial Flutter
      2. Ectopic Atrial Tachycardia
      3. Junctional Tachycardia
    2. Management
      1. Consider Consultation with cardiology
      2. Consider Synchronized Cardioversion if known onset (e.g. Atrial Flutter with rapid ventricular response)
      3. Treat underlying cause
        1. See Reversible Causes of Cardiopulmonary Arrest (5H5T)
      4. Rate control
        1. See Diltiazem and Metoprolol dosing under rate control as above

V. Management: Pregnancy

  1. Monitor both mother and fetus
  2. Women in pregnancy are more prone to supraventricular and ventricular Arrhythmias
    1. Increased Heart Rate, decreased Peripheral Vascular Resistance, increased Stroke Volume
  3. Safe measures
    1. Vagal Maneuvers
    2. AV Nodal Blockers (avoid in pre-excitation syndromes such as WPW)
      1. Adenosine
      2. Calcium Channel Blockers
        1. Teratogenicity in animals but not humans
        2. Risk of Fetal Bradycardia
    3. Procainamide
      1. Safe and well tolerated in pregnancy
    4. Cardioversion
      1. Avoid placing cardioversion pads over the Abdomen (place in typical chest positions)
      2. Minimal electrical penetration into Uterus
    5. Sedation
      1. Aspiration risk
      2. Avoid Hypotension
      3. Preferred sedation with Propofol or Ketamine
  4. Medications to avoid
    1. Beta Blockers
      1. IUGR risk
    2. Amiodarone
      1. Risk of exposing fetal Thyroid to high Iodine
      2. Risk of IUGR
      3. Risk of Preterm Labor
  5. References
    1. DeMeester and Cormack in Herbert (2021) EM:Rap 21(9): 10-2

VI. Management: Long-term management

  1. Infrequent episodes ("pill in the pocket" prn strategy)
    1. Diltiazem 120 mg orally AND Propranolol 80 mg orally once prn
    2. Flecainide 3 mg/kg orally once prn
    3. Alboni (2001) J Am Coll Cardiol 37(2): 548-53 [PubMed]
  2. Frequent episodes
    1. Medication options
      1. Diltiazem 240 to 360 mg orally daily
      2. Metoprolol 25 to 100 mg orally twice daily
      3. Flecainide 50-100 mg orally daily divided every 8-12 hours
        1. Typically not prescribed by primary care (limited to cardiology in most cases)
    2. Do not use long-term prophylaxis in Wolff-Parkinson-White Syndrome (WPW)
      1. Risk of Ventricular Fibrillation
      2. Consult for catheter ablation in symptomatic patients
  3. Radiofrequency ablation
    1. Accessory Pathway (e.g. WPW)
    2. Atrioventricular nodal reentrant Tachycardia
    3. Atrial Tachycardia

VII. References

  1. Swaminathan and Morgenstern in Herbert (2018) EM:Rap 18(7): 17-8
  2. (2000) Circulation, 102(Suppl I):86-9
  3. Helton (2015) Am Fam Physician 92(9): 793-800 [PubMed]

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Related Studies

Ontology: Paroxysmal supraventricular tachycardia (C0030590)

Definition (CHV) periods of very rapid heart beats that begin and end abruptly
Definition (CHV) periods of very rapid heart beats that begin and end abruptly
Definition (NCI) An electrocardiographic finding of episodic supraventricular tachycardia with abrupt onset and termination.
Concepts Disease or Syndrome (T047)
ICD9 427.0
SnomedCT 195074009, 266305002, 155363003, 67198005
English Paroxysm.supravent.tachyc. NOS, Paroxysmal supravent.tachycard, Paroxysmal supraventricular tachycardia NOS, PSVT, paroxysmal supraventricular tachycardia (diagnosis), paroxysmal supraventricular tachycardia, Paroxysmal tachycardia (supraventricular), Parox atrial tachycardia, paroxysmal supraventricular tachycardia (PSVT), psvt, Paroxysmal supraventricular tachycardia NOS (disorder), Paroxysmal sup. tachy., Tachycardia - parox.sup, Supravent. tach. parox., Paroxysmal Supraventricular Tachycardia by ECG Finding, Paroxysmal Supraventricular Tachycardia by EKG Finding, Paroxysmal Supraventricular Tachycardia, Paroxysmal supraventricular tachycardia (disorder), paroxysmal; tachycardia, supraventricular, tachycardia; paroxysmal, supraventricular, Paroxysmal supraventricular tachycardia, Tachycardia;supraventr;paroxys
Dutch paroxysmale supraventriculaire tachycardie, paroxysmale tachycardie (supraventriculair), paroxysmaal; tachycardie, supraventriculair, tachycardie; paroxysmaal, supraventriculair
French Tachycardie paroxystique supraventriculaire, Tachycardie paroxystique (supraventriculaire)
German paroxysmale supraventrikulaere Tachykardie, paroxysmale Tachykardie (supraventrikulaer)
Italian Tachicardia parossistica (sopraventricolare), Tachicardia parossistica sopraventricolare
Portuguese Taquicardia supraventricular paroxística
Spanish Taquicardia supraventricular paroxística, Taquicardia paroxística (supraventricular), taquicardia paroxística supraventricular, SAI (trastorno), taquicardia paroxística supraventricular, SAI, taquicardia supraventricular paroxística (trastorno), taquicardia supraventricular paroxística
Japanese 発作性頻脈（上室性）, 発作性上室性頻脈, ﾎｯｻｾｲﾋﾝﾐｬｸｼﾞｮｳｼﾂｾｲ, ﾎｯｻｾｲｼﾞｮｳｼﾂｾｲﾋﾝﾐｬｸ
Czech Paroxysmální tachykardie (supraventrikulární), Paroxysmální supraventrikulární tachykardie
Hungarian Paroxysmalis supraventricularis tachycardia, Paroxysmalis tachycardia (supraventricularis)
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Supraventricular tachycardia (C0039240)

Definition (NCI) A disorder characterized by an electrocardiographic finding of a tachycardia which does not originate in the ventricles or His Purkinje system. There is an abnormally high heart rate and QRS complexes are typically narrow, but aberration or preexcitation may be present. (CDISC)
Definition (NCI_CTCAE) A disorder characterized by a dysrhythmia with a heart rate greater than 100 beats per minute that originates above the ventricles.
Definition (MSH) A generic expression for any tachycardia that originates above the BUNDLE OF HIS.
Concepts Disease or Syndrome (T047)
MSH D013617
ICD10 I47.1
SnomedCT 195104006, 266305002, 155363003, 6456007
LNC LA17100-1
English Supraventricular Tachycardias, Tachycardia, Supraventricular, Tachycardias, Supraventricular, SVT, TACHYCARDIA SUPRAVENTRICULAR, Supraventric. tachycardia NOS, Supraventricular tachycardia NOS, SVT - Supraventricular tachy, supraventricular tachycardia (diagnosis), supraventricular tachycardia, Tachycardia supraventricular, Tachycardia, Supraventricular [Disease/Finding], tachycardia supraventricular, supraventricular tachycardias, Supraventricular tachycardia (SVtach), Supraventricular tachycardia NOS (disorder), SVT - Supraventricular tachycardia, Supraventricular tachycardia (disorder), supraventricular; tachycardia, tachycardia; supraventricular, Supraventricular tachycardia, NOS, Supraventricular tachycardia, Supraventricular Tachycardia
French TACHYCARDIE SUPRAVENTRICULAIRE, TSV, Tachycardie supraventriculaire, Tachycardie supra-ventriculaire
Portuguese TAQUICARDIA SUPRAVENTRICULAR, Taquicardia supraventricular, Taquicardia Supraventricular
Spanish TAQUICARDIA SUPRAVENTRICULAR, TSV, taquicardia supraventricular, SAI (trastorno), taquicardia supraventricular, SAI, taquicardia supraventricular (trastorno), taquicardia supraventricular, Taquicardia supraventricular, Taquicardia Supraventricular
Dutch tachycardie supraventriculair, SVT, supraventriculair; tachycardie, tachycardie; supraventriculair, supraventriculaire tachycardie, Supraventriculaire tachycardie, Tachycardie, supraventriculaire
German SVT, Supraventrikulaere Tachykardie, TACHYKARDIE SUPRAVENTRIKULAER, Tachykardie supraventrikulaer, Supraventrikuläre Tachykardie, Tachykardie, supraventrikuläre
Japanese 上室性頻脈, ｼﾞｮｳｼﾂｾｲﾋﾝﾐｬｸ
Swedish Takykardi, supraventrikulär
Finnish Supraventrikulaarinen takykardia
Russian TAKHIKARDIIA SUPRAVENTRIKULIARNAIA, TAKHIKARDIIA NADZHELUDOCHKOVAIA, ТАХИКАРДИЯ НАДЖЕЛУДОЧКОВАЯ, ТАХИКАРДИЯ СУПРАВЕНТРИКУЛЯРНАЯ
Czech SVT, Tachykardie supraventrikulární, Supraventrikulární tachykardie, supraventrikulární tachykardie, tachykardie supraventrikulární, supraventrikulární tachyarytmie
Korean 심실상성 빠른맥
Polish Svt, Tachykardia nadkomorowa, Częstoskurcz nadkomorowy
Hungarian SVT, Tachycardia, supraventricularis, Supraventricularis tachycardia
Norwegian Supraventrikulær takykardi
Italian Tachicardia sopraventricolare
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Electrocardiogram

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