Management of Paroxysmal Supraventricular Tachycardia (PSVT)

Acute Management Algorithm

The American Heart Association recommends vagal maneuvers followed by adenosine as the first-line treatments for acute management of PSVT, while catheter ablation is the most effective long-term solution for recurrent symptomatic PSVT 1, 2, 3
Immediate synchronized cardioversion is recommended for patients with hemodynamically unstable PSVT when vagal maneuvers or adenosine are ineffective or not feasible 2, 4
Initial energy settings for cardioversion of SVT: 50-100 J (biphasic) 1
If initial shock fails, increase energy in a stepwise fashion 1
Vagal maneuvers, such as the Valsalva maneuver and carotid sinus massage, can terminate up to 25% of PSVTs 1, 2, 4
Adenosine is effective in terminating PSVT, with an initial dose of 6 mg IV rapid push through a large vein, followed by 20 mL saline flush 1, 5
Calcium channel blockers, such as intravenous diltiazem or verapamil, can be effective for acute treatment in hemodynamically stable patients 2, 3
Beta blockers are reasonable for acute treatment in hemodynamically stable patients, although less effective than diltiazem in terminating SVT 6, 3

Catheter ablation is the first-line therapy for recurrent symptomatic PSVT, with high success rates and low complication rates 7, 6
Electrophysiological study with ablation is useful for diagnosis and definitive treatment 6, 7
Oral beta blockers, diltiazem, or verapamil are first-line pharmacological options for symptomatic patients without ventricular pre-excitation 6, 7, 8
Flecainide or propafenone are second-line pharmacological options for patients without structural heart disease or ischemic heart disease 6, 7

Synchronized cardioversion is recommended for hemodynamically unstable patients with pre-excited AF in WPW syndrome 4
Ibutilide or intravenous procainamide can be used for hemodynamically stable patients with pre-excited AF in WPW syndrome 4
AV nodal blocking agents, such as adenosine, beta blockers, calcium channel blockers, and digoxin, should be avoided in patients with WPW syndrome and pre-excitation 4, 5
Patients should be educated on proper technique for performing vagal maneuvers for self-management of PSVT episodes 6, 7

Patients with PSVT may experience palpitations (86%), chest discomfort (47%), dyspnea (38%), fatigue, lightheadedness, presyncope, or syncope, and polyuria may occur during episodes due to release of atrial natriuretic peptide 9

The American College of Cardiology recommends that patients with Wolff-Parkinson-White syndrome should always be evaluated for pre-excitation before starting calcium channel blockers, and for pre-excited AF in WPW syndrome, synchronized cardioversion is recommended for hemodynamically unstable patients, while ibutilide or intravenous procainamide may be used for hemodynamically stable patients 9

If initial adenosine dose fails, a second dose of 12 mg IV rapid push may be administered, as recommended by the American College of Cardiology 10
Alternative agents such as IV diltiazem or verapamil (calcium channel blockers) are highly effective for patients who are contraindicated for or fail adenosine treatment, according to the American College of Cardiology 10

Adenosine may precipitate atrial fibrillation in 1-15% of patients, particularly problematic in those with ventricular pre-excitation, as noted by the American College of Cardiology 10
Adenosine should be avoided in patients with severe bronchial asthma, as cautioned by the American College of Cardiology 10
Extreme caution should be used when administering concomitant IV calcium channel blockers and beta blockers due to potentiation of hypotensive/bradycardic effects, as advised by the American College of Cardiology 10
Monitoring for atrial or ventricular premature complexes after conversion is crucial, as they may trigger recurrence, according to the American College of Cardiology 10