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paroxysmal supraventricular tachycardia (PSVT)

Regular narrow-complex tachycardia with an abrupt onset & termination. Etiology: 1) AV nodal re-entrant tachycardia (most common in adults) 2) orthodromic AV reciprocating tachycardia (most common in children) 3) Wolf-Parkinson-White syndrome (WPW) Clinical manifestations: 1) palpitations 2) lightheadedness 3) syncope or presyncope 4) neck-pounding is associated with AV nodal re-entrant tachycardia Special laboratory: 1) electrocardiogram: a) narrow-complex tachycardia* with rate of 130-240/min b) a short R-P or P wave within ST segments suggests re-entry with - anterograde conduction through AV node - retrograde conduction through bypass tract c) P wave after T wave: no accessory conduction d) no P wave: re-entry simultaneously activates atria & ventricles [2] 2) event recorder better than HOLTER 3) electrophysiologic testing * QRS complexes may be wide if: - bundle branch block - aberrancy - pacing - anterograde accessory conduction pathway (WPW) Management: 1) wide QRS complex: see wide complex tachycardia - do not treat wide-complex tachycardia with adenosine [2] 2) narrow QRS complex a) generally a benign arrhythmia: - treatment indicated only for symptomatic patients - exception is patients with WPW b) acute measures - consider vagal maneuvers - carotid sinus massage* is most common maneuver - modified valsalva maneuver - 15-second, 40-mm Hg strain while in a semirecumbent position - follow immediately by supine repositioning (recline head bed) & passive leg raise to 45 degrees - repeat maneuver if not successful [3] - 43% success; NNT 3-4 - facial immersion in cold water [2] - adenosine 6 mg IV push, if no response in 1-2 min, 12 mg IV, push (may repeat once) - reduce dose in patients with history of cardiac transplantation - normal or elevated blood pressure, block AV node - verapamil 2.5-5 mg IV, then 5-10 mg IV or diltiazem - beta-blocker - digoxin - digoxin, amiodarone, diltiazem if LVEF < 40% - low or unstable blood pressure - synchronized cardioversion c) electrophysiologic testing with catheter ablation - significant hemodynamic compromise during tachycardia - syncope or presyncope - PSVT with evidence of pre-excitation (WPW) d) long-term pharmaco-therapy - beta-blocker - calcium channel blocker - short acting agents may be used at onset of tachycardia - propranolol 20 mg - verapamil 80 mg * Contraindicated in: 1) elderly 2) patients with carotid bruits 3) bilateral carotid sinus massage should never be performed

Related

Wolff-Parkinson-White (WPW) syndrome

Specific

AV nodal re-entrant tachycardia (AVNRT) orthodromic AV reciprocating tachycardia sinus node re-entrant tachycardia

General

supraventricular tachycardia (SVT)

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 105,182
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 17. 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2015, 2018, 2022. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Appelboam A et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): A randomised controlled trial. Lancet 2015 Aug 24 PMID:
  4. Link MS Clinical practice. Evaluation and initial treatment of supraventricular tachycardia. N Engl J Med. 2012 Oct 11;367(15):1438-48 PMID: 23050527
  5. Delacretaz E Clinical practice. Supraventricular tachycardia. N Engl J Med. 2006 Mar 9;354(10):1039-51. PMID: 16525141
  6. American Heart Association