Paroxysmal Supraventricular (PSVT)


Article Author:
Yamama Hafeez


Article Editor:
Shamai Grossman


Editors In Chief:
David Wood
Andrew Wilt
Mary Cataletto


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
5/14/2019 3:04:41 PM

Introduction

Atrioventricular node (AV) measures approximately 1 by 3 by 5  millimeters and sits within an anatomic region bordered anteriorly by septal tricuspid valve annulus, superiorly by the tendon of Todaro and posteriorly by the coronary sinus ostium. This anatomic region is also commonly referred to as the triangle of Koch. AV node is a subendocardial structure located in the inferior-posterior right atrium. The blood supply to the AV node is from the AV nodal branch of the right coronary artery  (90%) or the left circumflex artery (10%) depending on right or left dominant blood supply to the heart. The first septal perforator of the left anterior descending artery also supplies blood to the AV node.[1][2][3][4][5]

Paroxysmal supraventricular tachycardia (PSVT) accounts for intermittent episodes of supraventricular tachycardia with sudden onset and termination. PSVT is part of the narrow QRS complex tachycardias with a regular ventricular response in contrast to multifocal atrial tachycardia, atrial fibrillation, and atrial flutter. SVTs are classified based on the origin of the rhythm and whether the rhythm is regular or irregular.[6][7][8][9][10][11]

Atrial in origin and regular rhythm:

  • Sinus tachycardia
  • Inappropriate sinus tachycardia
  • Sinoatrial nodal reentrant tachycardia
  • Atrial flutter
  • Atrial fibrillation

Atrial in origin and irregular rhythm:

  • Multifocal atrial tachycardia
  • Atrial flutter with variable block
  • Atrial fibrillation

AV node in origin and regular rhythm:

  • Junctional tachycardia 
  • Atrioventricular nodal reentrant tachycardia
  • Atrioventricular reentrant tachycardia

AV node in origin and irregular rhythm:

  • None

Etiology

Numerous conditions and medications can lead to PSVT in patients. [6][12][13][14]

Some of these conditions and medications are listed below:

  • Hyperthyroidism
  • Caffeinated beverages
  • Nicotine
  • Hydralazine
  • Atropine
  • Adenosine
  • Verapamil
  • Salbutamol
  • Ecstasy
  • Cocaine
  • Amphetamines
  • Alcohol 
  • Digoxin toxicity
  • Myocardial infarction
  • Structural heart disease
  • Ebstein anomaly
  • Pericarditis
  • Myocarditis
  • Cardiomyopathy
  • Pulmonary embolism
  • Rheumatic heart disease
  • Mitral valve prolapse
  • Pneumonia
  • Chronic lung disease
  • Chest wall trauma
  • Anxiety
  • Hypovolemia
  • Hypoxia

Epidemiology

In the United States, the prevalence of PSVT is approximately 0.2%, and it has an incidence of one to three cases every thousand patients. The most common of the PSVT is atrial fibrillation with a prevalence rate of approximately 0.4% to 1% occurring in men and women equally, it is projected to affect as many as 7.5 million patients by 2050. The risk of developing PSVT was found to be twice in women as compared to men in a population-based study, with the prevalence of the PSVT higher with age. Atrioventricular nodal reentrant tachycardia is found more commonly in patients who are middle-aged or older. Whereas, PSVT with an accessory pathway is most common in adolescents and their occurrence decreases with age.[15][16][17]

Pathophysiology

PSVT is often due to different reentry circuits in the heart, where less frequent causes include enhanced or abnormal automaticity and triggered activity. Reentry circuits include a pathway within and around the sinus node, within the atrial myocardium, within the atrioventricular node or an accessory pathway involving the atrioventricular node.[18][19][20] Different types of PSVT result depending on the existing circuits, and examples are:

  • Sinus node: Sinoatrial node reentrant tachycardia
  • Atrial myocardium: Atrial flutter, atrial fibrillation, and multifocal atrial tachycardia
  • Atrioventricular node: Atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia

Histopathology

Under most circumstance, careful examination in patients with PSVT will show reentry circuits discussed above. No specific histopathologic findings are found in patients with PSVTs secondary to triggered activity and enhanced or abnormal automaticity.[20]

History and Physical

The severity of symptoms in patients with PSVT depends on any underlying structural heart disease, the frequency of PSVT episodes and the patient's hemodynamic reserve. Usually patients with PSVT present with symptoms of dizziness, syncope, nausea, shortness of breath, intermittent palpitations, pain/discomfort in the neck, pain/discomfort in the chest, anxiety, fatigue, diaphoresis, and polyuria secondary atrial natriuretic factor secreted mainly by the heart's atria in response to atrial stretch. Most common symptoms are dizziness and palpitations. Patients with PSVT and known history of coronary artery disease may present with a myocardial infarction secondary to the stress on the heart. Patients with PSVT and known history of heart failure may come in with acute exacerbation. Frequent PSVTs in a patient can result in new-onset of heart failure secondary to tachycardia-induced cardiomyopathy.[21]

A detailed history of the patient with PSVT should include past medical and cardiac history, time of symptom onset, prior episodes, and treatments. Patients' current medication list must be obtained. Investigations of involvement in physical activities such as exercise or outdoor sports should be made, as patients who have symptomatic PSVT's avoid such hobbies. Patients presenting with PSVTs should get a thorough physical exam including vital signs (respiratory rate, blood pressure, temperature, and heart rate) to help assess their hemodynamic stability.[22]

Evaluation

A significant component of evaluation for a patient who presents with signs and symptoms of PSVT is history and physical exam. These should include vital signs (respiratory rate, blood pressure, temperature, and heart rate), review of the patient's medication list and a 12-lead electrocardiogram. During an evaluation, a health care provider should establish if the patient is hemodynamically stable and whether they have any underlying ischemic heart disease or heart failure. A healthcare provider should consider thyroid function testing, pulmonary function testing, including routine blood work, and echocardiography as part of their initial evaluation of patients presenting with symptomatic PSVTs.[23][24]

Treatment / Management

Treatment of PSVT in a patient is dependent on the type of rhythm present on the electrocardiogram and the patient's hemodynamic stability. Patients presenting with hypotension, shortness of breath, chest pain, shock, or altered mental status are considered hemodynamically unstable, and their electrocardiogram evaluation must be done to determine if they are in sinus rhythm or not. If they are not in sinus rhythm, these patients should undergo urgent cardioversion. If they are determined to be in an appropriate sinus tachycardia than their underlying etiology must be treated, and for any manifestations of cardiac ischemia intravenous beta-blockers should be considered. If they have inappropriate sinus tachycardia on the electrocardiogram and are determined to be hemodynamically unstable, treatment with intravenous beta-blockers may be appropriate.[25][26][27]

If on initial evaluation, a patient is to found to be hemodynamically stable, then the treatment of the patient depends on the specific PSVT present on the electrocardiogram. If the 12-lead electrocardiogram shows that the rhythm is irregular and P waves are absent, then the patient should be appropriately treated for atrial fibrillation. If the rhythm on the electrocardiogram is irregular and flutter waves are present, then the patient should be treated for atrial flutter. If the rhythm on the electrocardiogram is irregular and multiple P wave morphologies are present, then the patient should be treated for multifocal atrial tachycardia.[28]

In patients who are hemodynamically stable and showing a regular rhythm with visible P waves on the electrocardiogram, then an assessment of the atrial rate, the relationship between the atrial and ventricular pacing, P-wave morphology and the P-wave position in the rhythm cycle is required. Type of PSVT present (atrial tachycardia, multifocal atrial tachycardia, atrial flutter, atrial flutter with a variable block, intra-atrial reentrant tachycardia, sinus tachycardia, sinoatrial node reentrant tachycardia, atrioventricular nodal reentrant tachycardia, atrioventricular reciprocating tachycardia, junctional ectopic tachycardia, and nonparoxysmal junctional tachycardia) determines the treatment.[29][30]

In patients who are hemodynamically stable and have electrocardiogram that shows a regular rhythm with undetectable P waves, Valsalva maneuvers, carotid sinus massage, or intravenous adenosine might be used to slow the ventricular rate or convert the rhythm into sinus rhythm and thus aid in the diagnosis. In some instances, increasing the electrocardiogram paper speed from 25 mm per second to 50 mm per second might help as well. If intravenous adenosine does not work, then intravenous or oral calcium channel blockers or beta-blockers should be used. Patients with PSVTs must also undergo evaluation for any underlying pre-excitation syndrome, and patients who fail medical treatment or those who might need radiofrequency catheter ablation need cardiology consultation.[31][32][33]

Differential Diagnosis

As below[34][35]:

  • Atrial tachycardia
  • Multifocal atrial tachycardia (MAT)
  • Atrial flutter
  • Atrial flutter with variable block
  • Atrial fibrillation
  • Intraatrial reentrant tachycardia
  • Sinus tachycardia
  • Inappropriate sinus tachycardia
  • Sinoatrial node reentrant tachycardia
  • Atrioventricular nodal reentrant tachycardia
  • Atrioventricular reciprocating (reentrant) tachycardia
  • Junctional ectopic tachycardia
  • Nonparoxysmal junctional tachycardia

Prognosis

In cases with no structural heart disease, the prognosis of PSVT is reasonably good.

Complications

If not identified promptly symptomatic complications such as syncope, fatigue or dizziness can occur. 

Deterrence and Patient Education

Educating patients at risk for this rhythm and making a closed loop communication between them and their providers can help further improve the management of these rhythms.

Pearls and Other Issues

Frequent PSVT can result in tachycardia-induced cardiomyopathy, a study on pregnant females found that PSVT in the first to second gestational month increase the chances of the child developing ostium secundum atrial septal defect.

Enhancing Healthcare Team Outcomes

If available patient education should be provided using resources familiar to the patient including online resources and pamphlets. 


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Paroxysmal Supraventricular (PSVT) - Questions

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A patient is found to a supraventricular tachycardia (SVT). Except for palpitations, he has no other symptoms. He has normal left ventricular function. Which of the following drugs is not used to treat SVT in such a scenario?



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A 28-year-old female with a past medical history of anxiety and depression presents with complaints of intermittent palpitations. She actively starts having palpitations during the physical exam. Her heart rate is 119 beats/min, blood pressure 113/92 mmHg, respiratory rate 17/minute, and temperature 97.8 F. An electrocardiogram shows a narrow QRS complex tachycardia with a regular rhythm. The patient fails to terminate the rhythm with vagal maneuvers and intravenous adenosine. What is the next best step to terminate a refractory paroxysmal supraventricular tachycardia?



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Which of the following is commonly used to treat persistent paroxysmal supraventricular tachycardia?



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What is the drug of choice for treating paroxysmal supraventricular tachycardia?



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Which of the following drugs can be given to terminate a refractory paroxysmal supraventricular tachycardia (PSVT)?



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What is the best initial treatment for paroxysmal supraventricular tachycardia?



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Select the patient that would best be treated with adenosine.



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Which of the following is the treatment of choice for a hemodynamically stable patient with paroxysmal supraventricular tachycardia?



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An adult patient presents with paroxysmal supraventricular tachycardia and a blood pressure of 80/60. What is the next best step in management?



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A patient with stable paroxysmal supraventricular tachycardia does not respond to vagal maneuvers. What is the next step in management?



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Which cardiac arrhythmia can be converted with the Valsalva maneuver?



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Paroxysmal supraventricular tachycardia is best treated by which of the following?



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A 46 year old male presents with regular, narrow complex tachycardia. He has a history of paroxysmal supraventricular tachycardia and felt the onset of palpitations 45 minutes ago. He is otherwise healthy. His initial vital signs were within normal limits with the exception of tachycardia of 152 beats per minute. Cardioversion is attempted with a valsalva maneuver and then 6 mg of adenosine without success and he has become increasingly confused. His current vital signs are HR 164 BP 86/42, RR 18, SPO2 100% RA. What is the next in management?



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A 61-year-old patient is found to have supraventricular tachycardia. Except for palpitations, he has no other symptoms. He has a normal left ventricular function. Which of the following drugs is not used to treat this arrhythmia in such a scenario?



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A 65-year old has been admitted to the intensive care unit for observation. He had fallen at home and is very confused and does not remember what happened. While he is on the cardiac monitor, the nurse calls you to tell you that the patient has supraventricular tachycardia. Which of the following is true about this particular arrhythmia?



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A 33-year-old African American female with past medical history of type 2 diabetes mellitus and depression presents to her primary care provider's clinic with symptoms of dizziness and palpitations. On physical examination, she has bounding neck veins with a regular heart rate of 173 bpm; blood pressure is 122/74 mmmHg, respiratory rate of 19/minute, and temperature of 98.0 F. What is the next step in the management of this patient?



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A 23-year-old white female with past medical history of allergic rhinitis presents to her primary care provider's clinic with symptoms of palpitations. On physical examination, she has bounding neck veins with a regular heart rate of 161 bpm; blood pressure is 122/73 mmHg, respiratory rate of 19/minute, and temperature of 97.7 F. Her electrocardiogram shows a regular narrow QRS complex rhythm with a pseudo-S wave in leads II, III, AVF and pseudo-R' in lead V1. Where in the heart is the reentry circuit most likely located?



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A 24-year-old white female with past medical history of dysmenorrhea presents to her primary care provider's clinic with symptoms of palpitations. On physical examination, there is a regular heart rate of 165 bpm; blood pressure is 121/87 mmHg, respiratory rate of 19/minute, and temperature of 97.6 F. Her electrocardiogram shows a regular narrow QRS complex rhythm with P waves between the QRS and T waves (QRS-P-T complexes). What is the next step in the management of this patient?



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A 47-year-old African American female with past medical history of paroxysmal supraventricular tachycardia, coronary artery disease, hypertension, and type 2 diabetes mellitus presents to the emergency department with symptoms of dizziness, palpitations, and chest pain. On physical examination, she has bounding neck veins with a regular heart rate of 174 bpm; blood pressure is 85/53 mmHg, respiratory rate of 21/minute, and temperature of 98.3 F. Her electrocardiogram shows a regular narrow QRS complex rhythm with a pseudo-S wave in leads II, III, AVF and pseudo-R' in lead V1. What is the next step in the management of this patient?



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Paroxysmal Supraventricular (PSVT) - References

References

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