Supraventricular tachycardia

Introduction

Any arrhythmia originating in the upper cardiac chambers with atrial rate greater than 100 beats/min.

Gradual onset = tachycardia gradually accelerates and decelerates (gradual shortening/prolongation of P-P interval.

Sudden onset = abruptly starts and ends, typically with symptoms.

We can divide these by duration on:

  • Paroxysmal supraventricular tachycardia (PSVT) – rapid tachycardia with ventricular rate usually > 120 beats/min, sudden onset and termination. (prevalence 2,25 per 1000 persons)
  • Non-paroxysmal/ incessant SVT – episodes of tachycardia alternate with the normal sinus rhythm at least 50% of the time or totally replace it. Usually 120-190 beats/min

Symptoms during SVT

  • palpitations
  • syncope or dizziness
  • chest pain, dyspnoea
  • polyuria (atrial stretch-induced atrial natriuretic peptide activity)
  • altered consciousness

Complications of SVT

  • worsened quality of life – anxiety, prolonged tiredness after an episode, fear of dying
  • paroxysmal SVT can degenerate into ventricular fibrillation – often fatal
  • incessant SVT – may develop into post-tachycardial cardiomyopathy
  • tachycardias over 150 bpm dramatically reduce cardiac output and coronary blood flow (diastole is very short),  potentially causing myocardial ischaemia. The faster the heart rate, the less well it will be tolerated


ECG features

A four-step approach to diagnose the underlying rhythm: 

  1. QRS complex
  • The width of the QRS complex during SVT is usually 80–100 ms
  • QRS can be wide >120ms e.g. in these situations:
    - if the patient has a permanent LBBB or RBBB
    - if during tachycardia a functional bundle branch block develops
    - if AV conduction during tachycardia is over an AV accessory pathway (AVNRT, AVRT)
  1. Is the rhythm regular or irregular?
  • regular – AVNRT, AVRT, atrial tachycardia or atrial flutter with stable conduction
  • irregular – atrial fibrillation, multifocal atrial tachycardia or atrial flutter with variable conduction (basically excludes AVNRT and AVRT)
  1. Presence and morphology of the P waves
  1. Duration of RP intervals
  • by this criteria, we can divide tachycardia to long RP and short RP


Picture 1 Differential diagnosis of narrow complex tachycardia


Management

Acute management

Initial treatment of SVT depends on hemodynamic stability of the patient.

  1. Hemodynamically unstable patient with narrow or wide complex tachycardia – urgent synchronized cardioversion
  2. Hemodynamically stable patient

Acute therapy of narrow complex tachycardia

Vagal manoeuvres

  • Carotid sinus massage - Pressure is applied to one carotid sinus for 5 to 10 seconds. Steady pressure is recommended because it may be more reproducible. If the expected response is not obtained, the procedure is repeated on the other side after a one- to two-minute delay.
  • Valsalva manoeuvres – patient is instructed to exhale forcefully against a closed glottis (against closed mouth and compressed nose) for 10 – 15s and then release.
  • Modified Valsalva manoeuvre – patient does classical Valsalva manoeuvre followed by 15 seconds of passive leg raise at 45 degree angle – this may be more successful in restoring sinus rhythm.

If this fails -

Adenosine – through cardiac adenosine A1 receptor > transient AV block

  • 6 mg i.v. as a rapid bolus with saline flush
  • second dose – 12 mg i.v., safe within 1 min of the last dose
  • maximum dose = 18 mg

Outcome:

  • AVNRT, AVRT > termination
  • atrial flutter, focal atrial tachycardia > demasking atrial rhythm during AV blockade
  • no response – probably underdosed or ventricular tachycardia
  • CAVE: contraindication in patients with asthma and patients with preexcitation on resting ECG!
  • Adenosine may induce a wide range of transient bradycardias as well as atrial fibrillation, SVT and ventricular tachycardia
  • Adenosine should always be administered with an external pacemaker or defibrillator nearby

If Vagal manoeuvres and adenosine application fails: 

  • Verapamil [0.075 - 0.15 mg/kg i.v. (average 5 - 10 mg) over 2 min] or i.v. diltiazem [0.25 mg/kg (average 20 mg) over 2 min] has been shown to terminate SVT in 64-98% of patients, but is associated with a risk of hypotension
  • application intravenously over 20 minutes has been shown to reduce the rate of hypotension
  • i.v. esmolol - 0.5 mg/kg i.v. bolus or 0.05 - 0.3 mg/kg/min infusion
  • i. v. metoprolol - 2.515 mg given i.v. in 2.5 mg boluses

If all pharmacological therapies fail - synchronized cardioversion is recommended, even in hemodynamically stable patients.

Chronic management

  • catheter ablation
  • paroxysmal tachycardia – vagal maneuvers, “pill in the pocket” – BB, verapamil, flecainide
  • symptomatic, incessant tachycardia
    - pharmacological therapy – BB, verapamil
    - radiofrequency catheter ablation


Acute therapy of wide complex tachycardia

  • Vagal manoeuvres
  • Adenosine – if there is no evidence of preexcitation on resting ECG
  • if ineffective:
    - Procainamide (i.v.) should be considered if vagal manoeuvres and adenosine fail.
    - Amiodarone (i.v.) may be considered if vagal manoeuvres and adenosine fail.
  • If drug therapy fails -synchronized cardioversion – to convert or control the tachycardia.

Picture 2 and 3  Treatment of narrow and wide complex tachycardias as per ESC guidelines



References

  1. CAMM, A. J., LÜSCHER, T. F., & SERRUYS, P. W. (2009). The ESC textbook of cardiovascular medicine. Oxford, Oxford University Press
  2. HARRIGAN, Richard A., William J. BRADY a Theodore C. CHAN. The ECG in Emergency Medicine. Emergency Medicine Clinics of North America [online]. 2006, 24(1) [cit. 2021-01-29]. ISSN 07338627. Dostupné z: doi:10.1016/j.emc.2005.08.001
  3. STRAUSS, David G., et al. Marriott's Practical Electrocardiography. Wolters Kluwer, 2021
  4. Josep Brugada, Demosthenes G Katritsis, Elena Arbelo, Fernando Arribas, Jeroen J Bax, Carina Blomström-Lundqvist, Hugh Calkins, Domenico Corrado, Spyridon G Deftereos, Gerhard-Paul Diller, Juan J Gomez-Doblas, Bulent Gorenek, Andrew Grace, Siew Yen Ho, Juan-Carlos Kaski, Karl-Heinz Kuck, Pier David Lambiase, Frederic Sacher, Georgia Sarquella-Brugada, Piotr Suwalski, Antonio Zaza, ESC Scientific Document Group, 2019 ESC Guidelines for the management of patients with supraventricular tachycardia The Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC): Developed in collaboration with the Association for European Paediatric and Congenital Cardiology (AEPC), European Heart Journal, Volume 41, Issue 5, 1 February 2020, Pages 655–720, https://doi.org/10.1093/eurheartj/ehz467
  5. Bibas, Lior et al. “Diagnosis and management of supraventricular tachycardias.” CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne vol. 188,17-18 (2016): E466-E473. doi:10.1503/cmaj.160079
  6. Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ, Campbell WB, Haines DE, Kuck KH, Lerman BB, Miller DD, Shaeffer CW, Stevenson WG, Tomaselli GF, Antman EM, Smith SC Jr, Alpert JS, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Hiratzka LF, Hunt SA, Jacobs AK, Russell RO Jr, Priori SG, Blanc JJ, Budaj A, Burgos EF, Cowie M, Deckers JW, Garcia MA, Klein WW, Lekakis J, Lindahl B, Mazzotta G, Morais JC, Oto A, Smiseth O, Trappe HJ; European Society of Cardiology Committee, NASPE-Heart Rhythm Society. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary. a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society. J Am Coll Cardiol. 2003 Oct 15;42(8):1493-531. doi: 10.1016/j.jacc.2003.08.013. PMID: 14563598.
  7. GARY HALS, MD, PHD, ATTENDING PHYSICIAN, RICHLAND MEMORIAL HOSPITAL, COLUMBIA, SC.; CHLOE MCCOY, MD, PHD, RICHLAND MEMORIAL HOSPITAL, COLUMBIA, SC.. Supraventricular Tachycardia: A Review for the Practicing Emergency Physician [online]. [cit. 30.1.2021]. Dostupný na WWW: https://www.reliasmedia.com/articles/135666-supraventricular-tachycardia-a-review-for-the-practicing-emergency-physician

Pictures:

Picture no. 1  HARAN BURRI. Oxford Medicine Online [online]. [cit. 30.1.2021]. Accessible at WWW: https://oxfordmedicine.com/oxford/fullsizeimage?imageUri=%2F10.1093%2Fmed%2F9780198784906.001.0001%2Fmed-9780198784906-graphic-41177-full.gif&uriChapter=%2F10.1093%2Fmed%2F9780198784906.001.0001%2Fmed-9780198784906-chapter-479

Picture no. 2  Acute therapy of narrow QRS tachycardia in the absence of an established diagnosis (2019). [Graph]. Accessible at: https://academic.oup.com/eurheartj/article/41/5/655/5556821

Picture no. 3 Acute therapy of wide complex tachycardia in the absence of an established diagnosis.[Graph]. Accessible at: https://academic.oup.com/eurheartj/article/41/5/655/5556821