Paroxysmal Supraventricular Tachycardia

Aka: Paroxysmal Supraventricular Tachycardia, PSVT

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II. Epidemiology

  1. Prevalence: 2-3 per 1000 persons (U.S.)
  2. Age (mean): 45 years old
  3. Gender
    1. Women represent 62% of cases (esp. middle aged women)

III. Types

  1. Atrioventricular Nodal Reentry (AVNRT)
  2. Atrioventricular Reciprocating Tachycardia (AVRT)
  3. Atrial Tachycardia

IV. Causes

  1. Triggers
    1. See Supraventricular Tachycardia
  2. Younger patients
    1. Typically no underlying structural heart disease
  3. Older patients (age over 50 years)
    1. Coronary Artery Disease
    2. Congestive Heart Failure
    3. Cardiomyopathy
    4. Valvular heart disease
  4. Uncommon Cardiac Causes
    1. Congenital Heart Disease
    2. Infiltrative Cardiomyopathy (e.g. Sarcoidosis, Tuberculosis)
    3. Electrical Disorders (e.g. Prolonged QT Syndrome, WPW)
    4. Prior Atrial Surgery

V. Symptoms: Episodic

  1. See Supraventricular Tachycardia
  2. Anxiety
    1. Episodes that have resolved before presentation are often misdiagnosed as Panic Attack
  3. Chest pressure
  4. Dyspnea
  5. Fatigue
  6. Light headed
  7. Palpitations

VI. Labs

  1. See Supraventricular Tachycardia
  2. Precautions
    1. Paroxysmal Supraventricular Tachycardia does not require routine labs in many cases (esp. known prior history of PSVT)
    2. Patients who are asymptomatic after PSVT resolves, and without underlying other risks need not undergo laboratory testing

VII. Diagnosis

  1. See Supraventricular Tachycardia
    1. Differentiate Sinus Tachycardia from other SVT

VIII. Management: Acute

  1. See Supraventricular Tachycardia Management in the Adult
  2. See Supraventricular Tachycardia Management in the Child
  3. ABC Management
  4. Mnemonic: IV-O2-Monitor
    1. Obtain IV Access
    2. Oxygen Delivery
    3. Cardiopulmonary monitor
  5. Hemodynamically Unstable Patients
    1. Do not delay Synchronized Cardioversion
  6. Stable patients
    1. Vagal Maneuvers
      1. First line measure in stable patients, and remarkably effective
    2. Adenosine 6 mg IV, then 12 mg IV
      1. Avoid if preexcitation (e.g. WPW) present
    3. Consider Synchronized Cardioversion
  7. Refractory PSVT with a narrow complex
    1. Metoprolol 5 mg IV over 1 to 2 minutes every 5 minutes as needed (up to 15 mg)
    2. Diltiazem 0.25 mg/kg IV over 2 minutes and may repeat after 15 min, at 0.35 mg/kg IV
  8. Refractory PSVT with a wide complex
    1. Procainamide
      1. Load 10 to 17 mg/kg IV at 20 to 50 mg/min
      2. Maintenance 1 to 4 mg/min IV
    2. Amiodarone IV
      1. Load 150 mg IV over 10 min (may repeat up to 1 dose)
      2. Next 1 mg/min for 6 hours
      3. Next 0.5 mg/min for 18 hours
      4. Max Total Loading Dose: 10 grams

IX. Management: Chronic

  1. Cardiology Referral
    1. See Supraventricular Tachycardia for indications
  2. Medical Management: Rate control agents
    1. Contraindications
      1. Preexcitation such as WPW Syndrome (refer for ablation)
      2. Heart Failure with Reduced Ejection Fraction (HFrEF)
    2. Medications
      1. Diltiazem 240 to 360 mg orally daily
      2. Metoprolol 50 to 400 mg/day
        1. Metoprolol Succinate (Toprol XL) once daily
        2. Metoprolol Tartrate (Lopressor) divided twice daily
  3. Medical Management: Antiarrhythmics
    1. Consult electrophysiology; higher risk agents
    2. Flecainide
    3. Propafenone
  4. Cardiac Ablation Indications
    1. AVNRT Indications
      1. Recurrent AVNRT
    2. AVRT Indications
      1. First-line in all cases
    3. Focal Atrial Tachycardia Indications
      1. Recurrent Focal Atrial Tachycardia
      2. Secondary Cardiomyopathy due to Atrial Tachycardia

X. References

  1. Nasir (2023) Am Fam Physician 107(6): 631-41 [PubMed]

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