Acute and Chronic Pharmacologic Management of Supraventricular Tachycardia (SVT)

Acute Management – First‑Line Adenosine

Adenosine is administered as 6 mg rapid IV bolus; if ineffective, a 12 mg bolus may be given and can be repeated once more at 12 mg. (European Society of Cardiology, ESC 2019 guideline) [1][2]3
Initial dose: 6 mg rapid IV bolus over 1–2 seconds, injected as proximally to the heart as possible, followed immediately by a rapid saline flush. (American College of Cardiology, ACC 2016 guideline) 3
Second dose: 12 mg rapid IV bolus if no conversion within 1–2 minutes. (ACC 2016) 3
Third dose: A further 12 mg bolus may be given once more if needed. (ACC 2016) 3
Pharmacokinetics: Adenosine half‑life is 0.6–10 seconds, making adverse effects transient. (ACC 2016) 3

Beta‑blockers are recommended as second‑line agents; the strength of recommendation was increased in the 2019 ESC guidelines. (ESC 2019) [1][2]
Esmolol: 500 µg/kg IV bolus over 1 minute, then continuous infusion 50–300 µg/kg/min with repeat boluses as needed. (ESC 2020) 1
Metoprolol tartrate: 2.5–5 mg IV bolus over 2 minutes; may be repeated every 10 minutes up to three doses. (ACC 2016) 3
Propranolol: 1 mg IV over 1 minute; may be repeated at 2‑minute intervals up to three doses. (ACC 2016) 3

Diltiazem: 0.25 mg/kg IV bolus over 2 minutes, followed by infusion 5–10 mg/h (maximum 15 mg/h). (ESC 2020) 2
Verapamil: 5–10 mg (0.075–0.15 mg/kg) IV bolus over 2 minutes; if no response, an additional 10 mg after 30 minutes, then infusion 0.005 mg/kg/min. (ACC 2016) 3

Do not use verapamil or diltiazem in wide‑QRS tachycardias of unknown origin because they can precipitate hemodynamic collapse if the rhythm is ventricular tachycardia. (ESC 2020) 1
Avoid adenosine in pre‑excited atrial fibrillation as it may trigger ventricular fibrillation. (ACC 2016) 3
Amiodarone and digoxin are no longer recommended for acute narrow‑QRS SVT. (ESC 2020) 1
Sotalol and lidocaine are no longer recommended for wide‑QRS tachycardias. (ESC 2020) 1

Beta‑blockers have a Class I recommendation for chronic management of AVNRT and AVRT. (ESC 2020) 2
Diltiazem or verapamil have a Class I recommendation for chronic AVNRT/AVRT when pre‑excitation is absent. (ACC 2016) 3
Flecainide or propafenone have a Class IIa recommendation for chronic AVNRT/AVRT in patients without structural heart disease. (ACC 2016) 3
Amiodarone, dofetilide, or sotalol have a Class IIb recommendation for chronic AVNRT/AVRT. (ACC 2016) 3
Digoxin has a Class IIb recommendation for chronic AVNRT/AVRT when pre‑excitation is absent. (ACC 2016) 3
The “pill‑in‑the‑pocket” approach is no longer recommended for AVRT or AVNRT. (ESC 2020) 2
Amiodarone, flecainide, propafenone, and sotalol have been downgraded for both acute and chronic AVNRT treatment. (ESC 2020) 2
Propranolol, procainamide, quinidine, and sotalol should not be used during pregnancy. (ESC 2020) 1

Inappropriate sinus tachycardia: Ivabradine alone or combined with beta‑blockers is newly recommended (though not EMA‑approved for this indication). (ESC 2020) 2
Inappropriate sinus tachycardia: Verapamil and diltiazem are no longer recommended. (ESC 2020) 1
Adults with congenital heart disease: Sotalol should be avoided as first‑line therapy. (ESC 2020) 2
Adults with congenital heart disease: Flecainide and propafenone should be avoided in patients with ventricular dysfunction, severe fibrosis, left bundle‑branch block, or ischemic/structural heart disease. (ESC 2020) 1

Both metoprolol and propranolol receive a Class I recommendation for chronic treatment of supraventricular tachycardia (AVNRT/AVRT) according to the American College of Cardiology/American Heart Association 2016 guideline and the European Society of Cardiology 2020 guideline, indicating that the evidence is strong and the therapy is recommended for all suitable patients. 4
For routine tachycardia management without specific fertility concerns, either metoprolol or propranolol may be selected as first‑line therapy based on the ACC/AHA and ESC guideline recommendations, reflecting interchangeable efficacy in the general population. 4

Abrupt discontinuation of beta‑blockers should be avoided, particularly in patients with coronary artery disease, as emphasized by the ACC/AHA guideline to prevent rebound tachycardia and ischemic complications; this recommendation carries a Class I level of evidence. 4