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clinical practice
Supraventricular Tachycardia
Etienne Delacrtaz, M.D.
This Journal feature begins with a case vignette highlighting a common clinical problem.
Evidence supporting various strategies is then presented, followed by a review of formal guidelines,
when they exist. The article ends with the authors clinical recommendations.
A 28-year-old woman suddenly has rapid palpitations accompanied by chest pain and
dizziness while playing her cello. She is brought to an emergency department. She has
a faint regular pulse of 190 beats per minute. Her blood pressure is 82/54 mm Hg.
Cardiovascular examination reveals no signs of heart failure. An electrocardiogram
shows a regular tachycardia with a narrow QRS complex and no apparent P waves.
How should her case be managed?
The term supraventricular tachycardia refers to paroxysmal tachyarrhythmias, From the Swiss Cardiovascular Centre
which require atrial or atrioventricular nodal tissue, or both, for their initiation and Bern, University Hospital Bern, Bern,
Switzerland. Address reprint requests to
maintenance. The incidence of supraventricular tachycardia is about 35 cases per Dr. Delacrtaz at Swiss Cardiovascular
100,000 persons per year, and the prevalence is about 2.25 per 1000 (excluding Center Bern, University Hospital Bern,
atrial fibrillation, atrial flutter, and multifocal atrial tachycardia, which are not CH-3010 Bern, Switzerland, or at etienne.
delacretaz@insel.ch.
covered in this review).1 Supraventricular tachycardias are often recurrent, occasion-
ally persistent, and a frequent cause of visits to emergency rooms and primary care N Engl J Med 2006;354:1039-51.
physicians. Copyright 2006 Massachusetts Medical Society.
Atrial tachycardia
Atrial flutter
Accessory
pathway
Orthodromic AV
reentrant tachycardia
AV nodal
reentrant
tachycardia
or
Antidromic
disease. These features are useful in distinguish- erate gradually; however, some patients do not per-
ing supraventricular tachycardia from other tachyar- ceive the sudden onset of supraventricular tachy-
rhythmias (Table 1). Supraventricular tachycardias cardia. It may be misdiagnosed as panic disorder.6
have a sudden onset and termination, in contrast Physical examination during episodes may re-
to sinus tachycardias, which accelerate and decel- veal the frog sign prominent jugular venous
* Atrial fibrillation and atrial flutter are not included in this category. AVRT denotes atrioventricular reentrant tachycardia.
In adults, sinus tachycardia is occasionally secondary to hyperthyroidism, anemia, infection, and heart failure. Sinus tachycardia may cause
symptoms that can be difficult to differentiate from those due to tachyarrhythmia.
Occasionally, ventricular tachycardia occurs in adults with no structural heart disease and is benign.
A waves due to atrial contraction against the closed is uncommon. Because electrolyte abnormalities
tricuspid valve.7 When sinus rhythm is restored, and hyperthyroidism may contribute to supraven-
physical examination is usually normal, but a care- tricular tachycardia, it is reasonable to check po-
ful examination is warranted to rule out evidence tassium and serum thyrotropin levels; however,
of structural heart disease. the tests for these values appear to have a low
The usual presentation of supraventricular yield.
tachycardia on electrocardiography (ECG) is as Electrophysiological testing allows for identi-
a narrow-QRS-complex tachycardia (a QRS in- fication of the mechanism of arrhythma, but
terval of less than 120 msec), but in some cases this procedure is generally performed only if
(less than 10 percent), wide-complex tachycardia catheter ablation is considered. Table 2 summa-
is the manifestation of supraventricular tachycar- rizes conditions for which this testing is gener-
dia. After the restoration of sinus rhythm, the ally recommended.
12-lead ECG should be examined for the presence
of delta waves, which indicate an accessory path- T r e atmen t
way (Fig. 2C). However, evidence of preexcita-
tion may be minimal or absent if the accessory short-term Therapy
pathway (e.g., a left lateral accessory pathway) is Figure 3 shows an algorithm for the management
located far from the sinus node or if, as occurs of acute supraventricular tachycardia. In rare cas-
in approximately 30 percent of patients, the ac- es, episodes of arrhythmia are so poorly tolerated
cessory pathways are concealed (i.e., they sup- that they require immediate electrical cardiover-
port exclusively retrograde conduction from the sion. Most supraventricular tachycardias depend
ventricle to the atrium and do not cause preexci- on the atrioventricular node for maintenance of
tation of the ventricle during sinus rhythm). In the reentry circuit and can be interrupted by va-
ambulatory patients with frequent episodes (two gal maneuvers or pharmacologic agents that slow
or more per month) of supraventricular tachycar- conduction through the atrioventricular node.
dia, ECG recordings or event recorders (which re-
cord arrhythmias for up to seven days) may be Vagal Maneuvers
useful to document arrhythmias. Massage of the carotid sinus stimulates barore-
An echocardiogram should be considered to ceptors, which trigger a reflexive increase in the
rule out structural heart disease, even though it activity of the vagal nerve and sympathetic with-
Table 2. Conditions Warranting Referral indicates that the tachycardia can usually be ter-
to an Electrophysiologist. minated by the administration of intravenous
Tachycardia with a wide QRS complex
verapamil or a beta-blocker.11,13,14 As a next step,
Supraventricular tachycardia
procainamide, ibutilide, propafenone, or flecainide
In a patient with syncope or severe symptoms
can be given intravenously if the patients blood
In a patient with drug resistance or intolerance
pressure is stable.15 However, sequential trials
In a patient who prefers to be free of drug therapy
with different antiarrhythmic agents should be un-
dertaken only after careful consideration of their
Preexcitation syndrome (with or without supraventricu-
lar tachycardia) possible negative hypotensive, bradycardic, and
proarrhythmic effects. At any point, electrical car-
dioversion is an alternative, but this technique
drawal, slowing conduction through the atrioven- is generally considered in patients in hemodyna-
tricular node. If the physical examination does not mically stable condition only if atrioventricular
reveal a carotid bruit and there is no history sug- nodal-blocking agents fail. Table 3 reviews medi-
gesting carotid artery disease, pressure may be cations used for acute supraventricular tachycar-
applied at the level of the cricoid cartilage for dia. These agents are contraindicated in patients
about five seconds with a firm circular movement. with severe hypotension, a history of heart block,
If the tachyarrhythmia persists, the procedure or congestive heart failure.
may be repeated on the opposite side. Other ap- Atrial fibrillation with rapid ventricular con-
proaches to increasing vagal tone include having duction can occur spontaneously in patients with
the patient perform a Valsalva maneuver or (pri- the WolffParkinsonWhite syndrome or during
marily in children) apply an ice pack to the face. treatment for supraventricular tachycardia. Emer-
A continuous 12-lead ECG recording of the gency-resuscitation equipment should be available,
episode should be obtained during vagal maneu- since the arrhythmia can degenerate into ven-
vers, since the way in which arrhythmias end may tricular fibrillation if the accessory pathway has
provide clues to their mechanism (Fig. 2).9 a short refractory period (250 msec or less).16
Treatment with an electrical shock is a safe option.
Adenosine If the patients condition is hemodynamically sta-
As with vagal maneuvers, treatment with intrave- ble, procainamide, ibutilide, propafenone, or fle-
nous adenosine has both diagnostic and thera- cainide may be used; all have a rapid onset of
peutic value. Data from randomized trials show action, lengthen antegrade refractoriness of the
that supraventricular tachycardia is terminated in accessory pathway, and terminate atrial fibrilla-
60 to 80 percent of patients treated with 6 mg of tion in the majority of cases.15
adenosine and in 90 to 95 percent of those treat-
ed with 12 mg.10 In patients with atrial tachycar- Wide-QRS-Complex Supraventricular Tachycardia
dias, adenosine causes a transient atrioventricular Supraventricular tachycardia presents infrequently
nodal block or interrupts the tachycardia (Table 3 as a wide-complex tachycardia, in which there is
and Fig. 2).10-12 ECG monitoring is required dur- an associated bundle-branch block or conduction
ing the administration of adenosine, and resusci- over an accessory pathway. Wide-QRS-complex,
tation equipment should be available in the event regular tachycardia should routinely be treated as
that the rare complications of bronchospasm or ventricular tachycardia, unless the diagnosis of
ventricular fibrillation occur. Adenosine is contra- supraventricular tachycardia with aberrancy or of
indicated in heart-transplant recipients and should supraventricular tachycardia with preexcitation
be used cautiously in patients with severe obstruc- is certain. Adenosine and other atrioventricular-
tive lung disease. Adenosine is also contraindi- nodalblocking agents are ineffective and poten-
cated in patients with tachycardia with a wide tially deleterious in patients with ventricular tachy-
QRS complex (unless the diagnosis of supraven- cardia.
tricular tachycardia with aberrancy is certain).
Long-Term Management
Other Agents The risk of recurrence after a single episode of
If supraventricular tachycardia is refractory to supraventricular tachycardia is not well defined,
adenosine or rapidly recurs, clinical experience and a single episode is not an indication for long-
Regular tachycardia
Hemodynamically Hemodynamically
stable unstable
Narrow-QRS complex
Wide-QRS complex
(<1 20 msec)
Electrical cardioversion
(rhythm strip and, if
possible, 12-lead ECG)
Vagal maneuvers
Continuous
No effect
12-lead ECG
recording Short-term therapy
for VT
IV adenosine, 6 mg
Repeat with 12 mg
term therapy. For patients with recurrent episodes, Figure 4 shows a decision algorithm for the
options for long-term treatment include medica- long-term care of patients with supraventricular
tion and ablation therapy. However, not all patients tachycardia. In cases in which the precise mech-
with recurrent supraventricular tachycardia need anism of tachycardia is uncertain, management
treatment. The severity of the symptoms and pa- is based on the presence or absence of preexcita-
tient preferences should be considered in decision tion on the baseline ECG (Table 3 and Fig. 4).
making. Referral to an electrophysiologist is war-
ranted for the conditions listed in Table 2 and Pharmacologic Therapy
should be considered in other cases to assist in Patients with recurrent episodes of supraventric-
decisions regarding therapy.17,18 ular tachycardia without preexcitation may be
* These agents have been tested in randomized trials. Electrocardiographic monitoring and blood-pressure monitoring are required during
treatment. Emergency-resuscitation equipment should always be available. If the diagnosis is certain, SVT with bundle-branch block may
be treated as tachycardia with a narrow QRS complex.
Adenosine is administered through rapid intravenous injection over a period of one to two seconds at a peripheral site, followed by an infu-
sion of 0.9 percent saline.
Preexcitation, syncope,
No preexcitation
or high-risk occupation
Pill in the
No therapy
pocket
Unsatisfactory
Prophylactic treatment:
beta-blockers, verapamil, Recurrence Electrophysiological testing
diltiazem, digoxin, or intolerance and catheter ablation
or combination
Unsatisfactory
and no consent Failed or
for catheter inappropriate
ablation
Prophylactic treatment:
Cure
class IC or class III
antiarrhythmic drugs
treated with prophylactic antiarrhythmic agents. none, sotalol, or amiodarone). In randomized, pla-
Patients with atrioventricular nodal reentrant cebo-controlled trials, class IC and class III anti-
tachycardia and atrioventricular reentrant tachy- arrhythmic drugs have prevented the recurrence
cardia mediated by a concealed accessory path- of supraventricular tachycardia in up to 80 percent
way should primarily receive atrioventricular-node of patients over a 60-day period of follow-up;
blocking agents such as verapamil, beta-blockers, these agents also appear to be more effective in
or digoxin. Clinical experience indicates that these preventing supraventricular tachycardia than are
agents decrease the frequency of the episodes and the atrioventricular-nodeblocking drugs, although
the severity of symptoms in an estimated 30 to data from comparative trials are lacking.20,21 De-
60 percent of patients, but complete suppression spite the apparent safety of class IC antiarrhyth-
of supraventricular tachycardia is uncommon.19 mic drugs in patients with supraventricular tachy-
A randomized, double-blind trial in which vera- cardia,22 long-term therapy with these drugs is
pamil, propranolol, and digoxin were compared generally not recommended because of their po-
failed to demonstrate the superiority of any one tential adverse effects (Table 4); catheter ablation
drug over the others.19 If treatment with the above- is usually preferred if the patient agrees to this
mentioned agents proves unsatisfactory, pharma- approach.
cologic options include a combination of two The pharmacologic management of atrial tachy-
atrioventricular node-blocking agents or a class cardias has not been well evaluated in controlled
IC or class III antiarrhythmic drug (e.g., propafe- trials. Depending on the mechanism causing the
terrupted within two hours with a combination rates are higher than 95 percent.34,36 Serious com-
of diltiazem and propanolol or with flecainide.23 plications are uncommon but include pulmonary
embolism (in up to 0.2 percent of patients) and the
Supraventricular Tachycardia with the Wolff development of atrioventricular block requiring
ParkinsonWhite Syndrome pacemaker therapy (in up to 1 percent of pa-
Verapamil and digoxin are contraindicated in pa- tients).33,34 Tachycardia recurs in 3 to 7 percent of
tients with the WolffParkinsonWhite syndrome, patients.36
unless the accessory pathway has been shown to Catheter ablation of focal atrial tachycardias
have a long refractory period (300 msec or more), has slightly lower success rates (about 85 percent)
because these drugs may increase the risk of rapid and higher recurrence rates (about 8 percent).36,37
ventricular response, causing ventricular fibrilla- Procedural risks are slightly increased for the treat-
tion in patients with atrial fibrillation.24,25 Al- ment of left atrial tachycardia, which requires a
though catheter ablation is considered the treat- transseptal puncture. For reentrant atrial tachy-
ment of choice for these patients, both flecainide cardias, radiofrequency ablation has high success
and propafenone are effective and have been ap- rates and is often used as first-line therapy.37-39
proved by the Food and Drug Administration for
the prevention of paroxysmal supraventricular A r e a s of Uncer ta in t y
tachycardias mediated by an accessory pathway
(with or without antegrade conduction).26-28 Limited data suggest that, as compared with an-
tiarrhythmic therapy, catheter ablation improves
Catheter Ablation the quality of life and is more cost effective in the
Since the early 1990s, catheter ablation (Fig. 5) has long term.40,41 However, there is a lack of large
increasingly been used in the management of su- randomized trials with prolonged follow-up to
praventricular tachycardia on the basis of its ob- guide the choice between radiofrequency ablation
served efficacy and overall safety when performed and medical therapy.
at centers with experienced clinicians. Observa- The appropriate treatment strategy for patients
tional studies of catheter ablation of tachycardia with asymptomatic preexcitation syndromes is
mediated by an accessory pathway indicate that controversial.42-44 The incidence of sudden death
success rates exceed 95 percent and recurrence due to rapid conduction of atrial fibrillation that
rates are less than 5 percent during the first few leads to ventricular fibrillation is estimated at be-
months after the procedure is performed. Late re- tween 0.15 and 0.45 percent per patient-year.45-47
currences are the exception.29-31 In cases in which Attempts to stratify the risk according to the use
the accessory pathway is close to a His bundle, of noninvasive methods or invasive measurements
the application of radiofrequency current can be of the refractory period of the accessory pathway
complicated by atrioventricular block that requires have been advocated but may be misleading.17,44,48
pacemaker therapy. Data from observational stud- A task force of the American College of Cardi-
ies suggest that in this situation, the use of cryo- ology, the American Heart Association, and the
thermal ablation is similarly effective and reduces European Society of Cardiology concluded that
the potential for atrioventricular block, although the positive predictive value of invasive electro-
studies directly comparing these approaches are physiologic testing is too low to justify its rou-
lacking.32 Other complications associated with tine use in asymptomatic patients and that the
accessory-pathway ablation, occurring in less than decision to ablate accessory pathways in persons
2 to 3 percent of patients, include damage to an with high-risk occupations or those who engage
artery, bleeding, arteriovenous fistula, venous in high-risk recreational activities should be made
thrombosis, pulmonary embolism, myocardial per- on an individual basis.8
foration, valvular damage, systemic embolism (in
the case of a left-sided accessory pathway), and Guidel ine s
rarely, death.33,34
In patients with atrioventricular nodal reentrant Comprehensive guidelines for the management of
tachycardia, the atrioventricular nodal slow path- supraventricular tachycardia were published by an
way is targeted by catheter ablation in the postero- expert committee of the American College of Car-
septal region of the tricuspid annulus.35 Success diology, the American Heart Association, and the
Dispersive
electrode
Radiofrequency-current
generator
Ablation
catheter
AV
node
Ablation
catheter
For patients in whom supraventricular tachy- 100 to 200 mg of flecainide) at the onset of su-
cardia recurs, preventive therapy is generally war- praventricular tachycardia is a reasonable ap-
ranted if there are frequent, prolonged, or highly proach. Catheter ablation, when performed at a
symptomatic episodes that cannot easily be ter- center with experienced clinicians, is appropri-
minated by the patients use of vagal maneuvers. ate for supraventricular tachycardia associated
If the tachycardia is associated with preexcitation with preexcitation or hemodynamic instability
or syncope, electrophysiological evaluation is or if antiarrhythmic drugs are not effective or
warranted. In the absence of preexcitation or are poorly tolerated. Catheter ablation may also
syncope, atrioventricular-nodeblocking agents be used as primary therapy in other cases if the
are usually recommended as first-line treatment, patients, informed of the risks and benefits,
even though there is a lack of data from large prefer this approach.
trials to compare these drugs with other ap- Supported by a grant from the Swiss National Science Foun-
proaches to management. However, many pa- dation.
Dr. Delacrtaz reports having received lecture fees, grant sup-
tients may have adverse effects or find it incon- port, or both, from Guidant, Medtronic, Merck, Rahn, Astra-
venient to take medication over the long term. Zeneca, and Pfizer. No other potential conflict of interest rele-
For patients in whom recurrences are infrequent vant to this article was reported.
I am indebted to Melanie Price, Ph.D., and Anne Zanchi, M.D.,
but prolonged, pill-in-the-pocket treatment (e.g., for their careful review of the manuscript.
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