Supraventricular tachycardia (SVT)

Supraventricular tachycardia (SVT) is when your heart

beats too fast. Its caused by faulty electrical signals in
your heart and often affects young, healthy people. SVT is
a type of arrhythmia, which means an abnormal heartbeat.
Supraventricular means the problem starts in the upper part of
your heart, above your ventricles (the lower chambers of your
heart). Tachycardia means a rapid heart rate of more than 100
beat per minute.

Causes of supraventricular tachycardia

The cause of supraventricular tachycardia (SVT) including:

taking certain medicines such as asthma

medications, herbal supplements and cold remedies

emotional upset or physical stress

hormonal changes

alcohol

caffeine

smoking lots of cigarettes

taking illegal drugs, such as cocaine or ecstasy

problems with your heart that you may have since

birth (congenital heart disease)

Symptoms of supraventricular tachycardia

Symptoms you may get during an episode of SVT include:

being aware of your heart suddenly beating faster (heart

palpitations)

feeling dizzy-lack of cerebral perfusion cause by poor

blood flow to the brain

feeling short of breath

chest pain

fainting

sweating

anxiety

Diagnosis of supraventricular tachycardia

Medical history taking -about your symptoms occur during
resting or activity and duration of palpitation
check blood pressure, listen to heartbeat and check pulse and
saturation.
electrocardiogram (ECG). An ECG records the electrical activity
in of heart to see how well it's working.
If suspects that have supraventricular tachycardia (SVT), you
may have some of the following tests to confirm it.

Blood tests. These will check for substances that may be

causing SVT or other conditions that may be causing your
symptoms.

Ambulatory ECG/ Holter monitoring. This is a portable ECG

that takes a recording of your heartbeat while you go about
your usual daily activities, over 24 hours or longer.

Echocardiogram. This test uses ultrasound to provide a

clear image of your heart muscles and valves and can show
how well your heart is working.

Treatment of supraventricular tachycardia

The aim of treatment is to control your heart rhythm and rate.
You may not need any treatment at all, especially if your
symptoms are mild .

Mild symptoms --Modified life style

Your doctor may suggest you improve your heart health by:

drinking less alcohol and caffeine

not taking any illegal drugs, such as cocaine or ecstasy

stopping smoking (if you smoke)

doing 30minutes of moderate exercise 5 days a week

Vagal Maneuvers
The first-line treatment in hemodynamically stable patients, vagal maneuvers,
such as breath-holding and the Valsalva maneuver (ie, having the patient bear
down as though having a bowel movement), slow conduction in the AV node
and can potentially interrupt the reentrant circuit.

Carotid massage
If doctor applies pressure to an artery in your neck, it may help
to slow the heart rate. However, it can be dangerous to do on
elderly people and doctor will need to check whether you're
suitable for this technique. Due to the risk of stroke from emboli,
auscultate for bruits before attempting this maneuver

Emergency treatments for unstable SVT

Adenosine
Adenosine is the first-line medical treatment for the termination of paroxysmal
SVT. It is a short-acting agent that alters potassium conductance into cells and
results in hyperpolarization of nodal cells. This increases the threshold to trigger
an action potential and results in sinus slowing and the blockage of AV
conduction.
First dose of Adenosine 6mg should be administered rapidly over 1 to 3 sec is
effective in terminating of SVT followed by 20ml NS.If the patient rhythm dose
not converted within 1 to 2 minute a second dose of 12mg dose maybe given in
similar patient. All efforts should be made to administer adenosine as quikly as
possible As a result of its short half-life, adenosine is best administered in an
antecubital vein as an intravenous bolus,

Typical adverse effects of adenosine include flushing, chest pain, and dizziness.
These effects are temporary because adenosine has a very short half-life of 1020 seconds.[54]

Electrical cardioversion
Electrical cardioversion is the most effective method for restoring sinus rhythm.
Synchronized cardioversion starting at 50J can be used immediately in patients
who are hypotensive, have pulmonary edema, have chest pain with ischemia, or
are otherwise unstable.
This uses an electric shock to restore your rapid heartbeat back to normal.

The patient should be adequately sedated with a short-acting agent such

as midazolam or propofol. In addition, an opioid analgesic, such as fentanyl,
is commonly used. Reversal agents, such as flumazenil and naloxone, should
be available.

The defibrillator should be placed in the synchronized mode, which

permits a search for a large R or S wave. The delivered energy is selected.
Most monophasic and biphasic models can deliver up to 360 Joules. Manual
button depression by the operator causes the defibrillator to discharge an
electric current that lasts less than 4 milliseconds and avoids the vulnerable
period of cardiac repolarization when VF can be induced. The operator should
be aware of this brief delay as the cardioverter searches for a large positive or
negative deflection. If deflections are too small for the defibrillator to
synchronize, the physician can change the leads or place them closer to the
patient's chest or heart. If the patient develops VF, always turn off
synchronization to avoid delay in energy delivery.
Synchronization avoids the delivery of a LOW ENERGY shock during
cardiac repolarization (t-wave). If the shock occurs on the t-wave
(during repolarization), there is a high likelihood that the shock can
precipitate VF (Ventricular Fibrillation).

Unsynchronized cardioversion (defibrillation) is a HIGH ENERGY

shock which is delivered as soon as the shock button is pushed on a
defibrillator. This means that the shock may fall randomly anywhere within the
cardiac cycle (QRS complex). Unsynchronized cardioversion (defibrillation) is

used when there is no coordinated intrinsic electrical activity in the heart

(pulseless VT/VF) or the defibrillator fails to synchronize in an unstable patient.

Hospital treatment
Electrophysiological study. In this test, a thin, flexible wire (catheter) is passed
through a vein in your groin or arm to your heart. The wire records your heart's
electrical activity. Your doctor can use the wire to electrically stimulate your
heart and it will burn or freeze any tissue that's disrupting or causing abnormal
electrical signals.

Complications of supraventricular tachycardia (SVT)

might happen because your heart rate isn't normal. As such, your heart may
not be able to pump blood effectively around your body. This can result in
low blood pressure, which may cause fainting. Low blood pressure may
also result in less blood flowing to your heart. This can damage your heart
muscle and cause heart to pump less effectively, which may
result in heart failure or a heart attack. Complications are
rare. They may be more likely if you have other problems
with your heart.

Types of medicine that can help control your heart rate and
rhythm. These include beta-blockers, calcium-channel blockers
and antiarrhythmic medicines. You can also take them to prevent
further SVT episodes.
Antiarrhythmic agents
Flecainide blocks sodium channels, producing a dose-related decrease in
intracardiac conduction in all parts of heart. The drug increases electrical
stimulation of threshold of ventricle, HIS-Purkinje system. Flecainide shortens
phase 2 and 3 repolarization, resulting in a decreased action potential duration
and effective refractory period.
This agent is indicated for the treatment of paroxysmal atrial fibrillation/flutter
(PAF) associated with disabling symptoms. It is also indicated for paroxysmal
SVTs, including atrioventricular nodal reentrant tachycardia (AVNRT),
atrioventricular Other alternatives for the acute treatment of SVT include
calcium channel blockers, such as verapamil and diltiazem, as well as beta-

blockers, such as metoprolol or esmolol. Verapamil is a calcium channel

blocker that also has AV blocking properties. It has a longer half-life than
adenosine and may help to maintain sinus rhythm following the termination of
SVT. It is also advantageous for controlling the ventricular rate in patients with
atrial tachyarrhythmia.
The choice of long-term therapy for patients with SVT depends on the type of
tachyarrhythmia that is occurring and the frequency and duration of episodes, as
well as the symptoms and the risks associated with the arrhythmia (eg, heart
failure, sudden death). Evaluate patients on an individual basis, and tailor
treatment to the best therapy for the specific tachyarrhythmia.
Patients with paroxysmal SVT may initially be treated with calcium channel
blockers, digoxin, and/or beta-blockers. Class IA, IC, or III antiarrhythmic
agents are used less frequently because of the success of radiofrequency
catheter
These medications are used to treat or prevent arrhythmia.

Flecainide (Tambocor)
Reentrant tachycardia (AVRT), and other SVTs of unspecified mechanism
associated with disabling symptoms in patients without structural heart disease.
In addition, Flecainide is indicated for the prevention of documented, lifethreatening ventricular arrhythmias, such as sustained ventricular tachycardia. It
is not recommended for less severe ventricular arrhythmias, even if patients are
symptomatic.
Propafenone is indicated for the treatment of documented, life-threatening
ventricular arrhythmias, such as sustained ventricular tachycardia. It appears to
be effective in the treatment of SVTs, including atrial fibrillation and flutter. The
drug is not recommended for patients with less severe ventricular arrhythmias,
even if the patients are symptomatic.

Digoxin (Lanoxin)
Digoxin indirectly increases vagal activity, thereby decreasing conduction
velocity through the AV node. This can result in termination of paroxysmal
SVT.
Calcium Channel Blockers
Class Summary

Class IV calcium channel blockers decrease the conduction velocity and

prolong the refractory period.
Verapamil (Isoptin, Calan, Verelan, Covera-HS)
Calcium channel blockers prevent calcium influx into the slow channels of the
AV node, decrease the conduction velocity, and prolong the refractory period,
which effectively terminates reentrant conduction.
Diltiazem (Cardizem, Tiazac, Dilacor XR)
Diltiazem is similar to verapamil. This agent decreases the conduction velocity
in the AV node and increases the refractory period via a blockade of calcium
influx. This, in turn, stops the reentrant phenomenon.

Beta-Blockers, Beta-1 Selective

Class Summary
These agents slow the sinus rate and decrease AV nodal conduction. Betablockers now have more of a secondary role in AF rate control. Carefully
monitor blood pressure.
Atenolol (Tenormin)
Atenolol selectively blocks beta-1 receptors, with little or no effect on beta-2
types. Atenolol is excellent for use in patients at risk for experiencing
complications from beta-blockade, particularly those with reactive airway
disease, mild-to-moderate LV dysfunction, and/or peripheral vascular disease.
Esmolol (Brevibloc)
Esmolol is a short-acting beta-blocker that abolishes reentry-induced
paroxysmal SVT by increasing the refractory period of the AV node.
It selectively blocks beta-1 receptors, with little or no effect on beta-2 receptor
types. It is particularly useful in patients with elevated arterial pressure,
especially if surgery is planned. It has been shown to reduce episodes of chest
pain and clinical cardiac events compared with placebo. It can be discontinued
abruptly if necessary. It is useful in patients at risk for experiencing
complications from beta-blockade, particularly those with reactive airway
disease, mild-to-moderate LV dysfunction, and/or peripheral vascular disease. A

short half-life of 8 min allows for titration to the desired effect and quick
discontinuation if needed.
Metoprolol (Lopressor, Toprol XL)
Metoprolol is a selective beta-1 adrenergic receptor blocker that decreases the
automaticity of contractions. During intravenous administration, carefully
monitor blood pressure, heart rate, and ECG.

Beta-blockers, Nonselective
Class Summary
These agents increase the refractory period of the AV node. Beta-blockers that
are effective in treating paroxysmal SVT include propranolol, esmolol,
metoprolol, atenolol, and nadolol.

Propranolol (Inderal LA, InnoPran XL)

Beta-blockers abolish reentry-induced paroxysmal SVT by increasing the
refractory period of the AV node.

Nadolol (Corgard)
Nadolol is frequently prescribed because of its long-term effect. It reduces the
effect of sympathetic stimulation on the heart. Nadolol decreases conduction
through the AV node and has negative chronotropic and inotropic effects.
Patients with asthma should use cardioselective beta-blockers.