Diagnosis and Management of Common Types of Supraventricular Tachycardia

 


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Am Fam Physician. 2015 Nov 1;92(9):793-802.

  Patient information: See related handout on supraventricular tachycardia.

  Related letter: Responsiveness to Adenosine Does Not Confirm SVT Diagnosis

Author disclosure: No relevant financial affiliations.

Supraventricular tachycardia refers to rapid rhythms that originate and are sustained in atrial or atrioventricular node tissue above the bundle of His. The condition is caused by reentry phenomena or automaticity at or above the atrioventricular node, and includes atrioventricular nodal reentrant tachycardia, atrioventricular reciprocating tachycardia, and atrial tachycardia. Most persons with these tachyarrhythmias have structurally normal hearts. Sudden onset of an accelerated heart rate can cause palpitations, light-headedness, chest discomfort, anxiety, dyspnea, or fatigue. The history is important to elicit episodic symptoms because physical examination and electrocardiography findings may be normal. A Holter monitor or event recorder may be needed to confirm the diagnosis. Vagal maneuvers may terminate the arrhythmia; 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. Class Ic antiarrhythmics (flecainide or propafenone) can be used long-term. Class Ia antiarrhythmics (quinidine, procainamide, or disopyramide) are used less often because of their modest effectiveness and adverse effects. Class III antiarrhythmics (amiodarone, sotalol, or dofetilide) are effective, but have potential adverse effects and should be administered in consultation with a cardiologist. Catheter ablation has a success rate of 95% and recurrence rate of less than 5%, and causes inadvertent heart block in less than 1% of patients. It is the preferred treatment for symptomatic patients with Wolff-Parkinson-White syndrome.

Supraventricular tachycardia (SVT) refers to rapid rhythms that originate and are sustained in atrial or atrioventricular nodal tissue, and then transmit through the bundle of His and cause rapid ventricular response. Although atrial flutter, atrial fibrillation, and multi-focal atrial tachycardia also arise from this area, in practice, SVT refers to atrioventricular nodal reentrant tachycardia (AVNRT), atrioventricular reciprocating tachycardia (AVRT), and atrial tachycardia. Figure 1 illustrates the three types of SVT.1 These arrhythmias typically occur in patients with structurally normal hearts, although patients with hypertrophic cardiomyopathy or a cardiac congenital anomaly may have accessory pathways.2 Sudden onset of an accelerated heart rate can cause palpitations, light-headedness, chest discomfort, anxiety, dyspnea, or fatigue.

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Valsalva maneuvers are effective in terminating SVT in hemodynamically stable patients.

B

21

Intravenous adenosine, verapamil, and diltiazem are effective in acute termination of SVT.

B

17, 24

Beta blockers (metoprolol, atenolol, propranolol, and esmolol) are effective in acute termination of SVT.

C

17

Adenosine may be used for diagnosis and treatment of undifferentiated regular wide complex tachycardia.

B

27

The Brugada criteria are sensitive and specific for distinguishing between SVT with aberrancy and ventricular tachycardia.

C

28

The “pill-in-the-pocket” approach is effective for infrequent SVT episodes.

B

30

Catheter ablation is a generally safe and effective treatment for SVT.

B

31, 32


SVT = supraventricular tachycardia.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Valsalva maneuvers are effective in terminating SVT in hemodynamically stable patients.

B

21

Intravenous adenosine, verapamil, and diltiazem are effective in acute termination of SVT.

B

17, 24

Beta blockers (metoprolol, atenolol, propranolol, and esmolol) are effective in acute termination of SVT.

C

17

Adenosine may be used for diagnosis and treatment of undifferentiated regular wide complex tachycardia.

B

27

The Brugada criteria are sensitive and specific for distinguishing between SVT with aberrancy and ventricular tachycardia.

C

28

The “pill-in-the-pocket” approach is effective for infrequent SVT episodes.

B

30

Catheter ablation is a generally safe and effective treatment for SVT.

B

31, 32


SVT = supraventricular tachycardia.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

View/Print Figure

Figure 1.

Types of supraventricular tachycardia. (A) In typical atrioventricular nodal reentrant tachycardia (antegrade conduction down the slow atrioventricular nodal pathway and retrograde conduction up the fast pathway), the retrograde P wave may not be seen

The Authors

MARGARET R. HELTON, MD, is a professor in the Department of Family Medicine at the University of North Carolina at Chapel Hill School of Medicine.

Address correspondence to Margaret R. Helton, MD, University of North Carolina at Chapel Hill, CB #7595, Chapel Hill, NC 27599-7595 (e-mail: margaret_helton@med.unc.edu). Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

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