Updated: 3/2/2021

Supraventricular Tachycardia

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Snapshot
  • A 28-year-old woman presents to the emergency department for palpitations and lightheadedness. She reports that her symptoms began approximately 20 minutes ago and it has not subsided. Medical history is significant for hyperthyroidism. Vital signs are significant for a blood pressure of 135/95 mmHg and a pulse of 155/min. An electrocardiogram is performed that shows a narrow QRS-complex tachyarrhythmia. Carotid sinus massage is performed and her symptoms do not improve. Intravenous adenosine is instituted and her pulse decreases to 79/min.  
Introduction
  • Definition
    • a tachyarrhythmia that originates above the ventricles (e.g., atrial or atrioventricular node tissues)
      • also known paroxysmal supraventricular tachycardia (SVT)
  • Epidemiology
    • precipitating factors
      • excessive caffeine or alcohol
      • hyperthyroidism
      • illicit drug use
  • Types
    • atrial fibrillation 
    • atrial flutter 
    • focal atrial tachycardia
    • multifocal atrial tachycardia 
    • atrioventricular reentrant tachycardia
    • atrioventricular nodal reentrant tachycardia
    • Wolff-Parkinson-White syndrome 
  • Etiology
    • reentrant circuit involved atrial and/or atrioventricular nodal tissue
  • Associated conditions
    • acute myocardial infarctions
    • preexcitation syndromes
    • atrial septal defects
    • chronic lung disease
Presentation
  • Symptoms
    • palpitations
    • anxiety
    • presyncope/lightheadedness
    • chest pain
  • Physical exam
    • tachycardia
Studies
  • Electrocardiogram
    • tachycardia
    • narrow or wide QRS complex
      • if a wide QRS complex is noted, it must be differentiated from a ventricular tachycardia
      • a wide QRS complex can be seen in SVT if there is
        • bundle branch block
        • accessory pathway
  • Holter monitor
    • consider a 24-hour Holter monitor in patients if the tachycardia is not present
Differential
  • Atrial fibrillation 
    • differentiating factor
      • narrow QRS complex with an irregularly irregular rhythm
Treatment
  • Conservative
    • vagal maneuvers 
      • indication
        • first-step in management in a stable patient
      • examples
        • carotid sinus massage
        • Valsalva
        • facial immersion in ice or a cold wet towel
  • Medical
    • intravenous adenosine   
      • indication
        • administered in stable patients who are unresponsive to vagal maneuvers
    • AV nodal blocking agents
      • beta-blockers
      • calcium channel blockers
        • contraindicated in patients < 12 months old (can cause hypotension and pulselessness) 
  • Procedural
    • synchronized cardioversion
      • indication
        • performed in hemodynamically unstable patients
    • radiofrequency catheter ablation
      • indication
        • best long-term therapy for SVT
Complications
  • Tachycardia-mediated cardiomyopathy

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Questions (5)
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(M2.CV.16.203) A 30-year-old woman with no significant past medical history presents to the emergency department stating that her heart has been racing for the past 4 hours. She denies experiencing any chest pain, shortness of breath, weakness, or confusion. Her vital signs are as follows: T 99F, HR 180, RR 14, BP 130/85, SaO2 100%. Her physical exam is normal aside from obvious tachycardia on cardiovascular exam. Her EKG is shown in Figure A, and it remains unchanged after Valsalva maneuver. Which of the following drugs should be administered at this time?

QID: 104209
FIGURES:
1

Nifedipine

0%

(0/6)

2

Adenosine

100%

(6/6)

3

Low-dose aspirin

0%

(0/6)

4

Fentanyl followed by synchronized cardioversion

0%

(0/6)

5

Esmolol

0%

(0/6)

M 7 E

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Evidence (5)
EXPERT COMMENTS (21)
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