Management of Paroxysmal Supraventricular Tachycardia (PSVT)

Acute Management

The American Heart Association recommends adenosine as the preferred first-line agent for acute termination of PSVT in hemodynamically stable patients due to its rapid action and short half-life 1
For intravenous verapamil in the acute setting, the recommended dose is 5-10 mg (0.075-0.15 mg/kg) IV bolus over 2 minutes 2
If no response to the initial dose of intravenous verapamil, an additional 10 mg (0.15 mg/kg) can be given 30 minutes after the first dose 2
The American Heart Association recommends giving verapamil as a 2.5-5 mg IV bolus over 2 minutes (over 3 minutes in older patients) if adenosine fails or is contraindicated 1

The recommended oral dose of Calan SR (verapamil) for patients with PSVT is 120 mg daily initially, which can be titrated up to a maximum of 480 mg daily in divided doses or as a single dose with long-acting formulations 3
Effectiveness of verapamil has been demonstrated in randomized controlled trials at doses up to 480 mg/day 4

Verapamil should not be given to patients with AV block greater than first degree or SA node dysfunction (in absence of pacemaker), decompensated systolic heart failure or severe LV dysfunction, hypotension, Wolff-Parkinson-White (WPW) syndrome with atrial fibrillation/flutter, or cardiogenic shock 3, 2
Hypotension is the most common adverse effect of verapamil 2
Worsening heart failure in patients with pre-existing ventricular dysfunction, bradycardia, and pulmonary edema in patients with hypertrophic cardiomyopathy are side effects to monitor 2

Verapamil works by slowing AV node conduction and increasing AV node refractoriness 5

For hemodynamically stable patients with SVT, the American Heart Association recommends first attempting vagal maneuvers 6, 7
Verapamil is an appropriate second-line agent for acute termination of PSVT if adenosine fails or is contraindicated, according to the American College of Cardiology 8

The initial dose of verapamil for SVT treatment is 2.5-5 mg IV bolus administered over 2 minutes, with a maximum total dose of 20-30 mg if needed, as recommended by the American Heart Association 8
Additional doses of 5-10 mg may be given every 15-30 minutes if no response is observed, with a maximum total dose of 20-30 mg, according to the American College of Cardiology 8

Verapamil is contraindicated in patients with Wolff-Parkinson-White syndrome with atrial fibrillation/flutter, impaired ventricular function or heart failure, and AV block greater than first degree, as stated by the European Society of Cardiology 6, 7
The American Heart Association recommends avoiding verapamil administration in patients with wide-complex tachycardias unless known with certainty to be supraventricular in origin, and in patients who have recently received β-blockers, due to the risk of profound bradycardia and hypotension 8, 6, 7

The maximum recommended daily dose of verapamil is 480 mg, which has been demonstrated effective in randomized controlled trials 9
EP study with ablation is a definitive treatment option with high success rates for acute termination of SVT 9
Beta blockers or diltiazem are alternative oral agents for ongoing management of SVT 9

ECG monitoring is advised to ensure effectiveness and detect potential conduction abnormalities 9
Patients should be educated on how to perform vagal maneuvers as complementary management for acute episodes 9