em training session supraventricular tachycardia 1. what is your first line management for svt &...
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EM training sessionSupraventricular tachycardia
1. What is your first line management for SVT & how effective is it? 2. What drug treatments can you try, what are pros/cons?3. Where did you obtain your evidence for the decisions above? And what resources do you use for education/information
Supraventricular tachycardia
Via Intranet “Do something else” link or www.dynamed.com Choose Institutional log-in and OpenAthens option.
Updated 2015 Mar 10 10:14:00 AM: Valsalva maneuver reported to have about 19% reversion rate in patients with spontaneous supraventricular tachycardia and about 50% in patients with electrically induced supraventricular tachycardia (Cochrane Database Syst Rev 2015 Feb 18)
Treatment overview: Acute management: •if unable to determine wide complex tachycardia is supraventricular in origin, treat as if ventricular tachycardia•emergent direct current (DC) synchronized shock if hemodynamically unstable (cardiogenic shock) or acute heart failure (ACC/AHA/ESC Class I, Level C) •for narrow QRS complex and wide QRS complex with bundle-branch block in patients who are hemodynamically stable
• attempt vagal stimulation (ACC/AHA/ESC Class I, Level B) • IV medication if unresponsive to vagal stimulation
• adenosine unless asthma or structural heart disease (ACC/AHA/ESC Class I, Level A)
• if unresponsive to adenosine, calcium-channel blockers (ACC/AHA/ESC Class I, Level A) • verapamil • diltiazem
• dosing• adenosine, start with 6 mg rapid bolus dose, then give 12 mg if unresponsive within 1-2 minutes
• verapamil 5 mg every 3-5 minutes to maximum 15 mg• diltiazem 0.25 mg/kg over 2 minutes, then additional 0.35 mg/kg over 2 minutes if unresponsive
Efficacy: adenosine and verapamil may have similar reversion rates, but adenosine associated with increased risks of relapse and minor side effects (level 2 [mid-level] evidence)
based on withdrawn Cochrane review of trials with incomplete reporting of trial detailssystematic review of 10 randomized trials comparing adenosine vs. calcium channel blockers in patients with supraventricular tachycardiaall trials had incomplete reporting of allocation concealment, blinding, and/or intention-to-treat analysisall trials used verapamil as calcium channel blockerno significant difference between groups in reversion rates (> 90% in both groups)adenosine associated with
shorter time to reversion in analysis of 4 trials with 278 patientsincreased risk of relapse to SVT in analysis of 4 trials with 247 patientsincreased risk of minor adverse events including
nauseachest tightnessdyspneaheadache
lower risk of hypotension in analysis of 6 trials with 489 patientsReference - Cochrane Database Syst Rev 2012 Feb 15;2:CD005154, commentary on earlier version can be found in Am Fam Physician 2007 Jun 1;75(11):1653 full-text
• Is Intravenous Adenosine Effective and Safe in Patients presenting with Unstable Paroxysmal Supraventricular Tachycardia?
• Report By:Dr.Adnan Gebril - StR in Emergency Medicine
• Three Part Question• In [patients with Unstable Paroxysmal Supraventricular Tachycardia] is [treatment
with intravenous Adenosine] both [effective and safe]?
Clinical Scenario• A 40-year-old woman with known paroxysmal supraventricular tachycardia (PSVT)
presents to the emergency department with an acute episode of palpitations, dizziness and chest tightness of sudden onset. She is found to have a further episode of supraventricular tachycardia on ECG and her systolic blood pressure is 55 mm Hg. Previous episodes have been terminated by DC cardioversion and you are aware of the algorithm recommending such treatment in the 2011 ALS course manual. However, the text also states that it is reasonable to give Adenosine to patients with regular narrow-complex tachyarrhythmias where there are adverse features while preparations are being made for synchronised cardioversion. You wonder whether it is really effective and safe to give adenosine first to unstable patients and whether this is so for children also.
• Comment(s)• No serious side-effects at all were reported in the eight papers we found looking at
the safety and efficacy of using adenosine in patients with unstable PSVT. There were only short-lived, transient side-effects such as headache, flushing, transient arrhythmias and chest tightness, which are well recognised effects in stable patients anyway. In addition, the efficacy of adenosine in converting patients to sinus rhythm is similar for both stable and unstable patients, although some of the papers looked at in this review do not specifically compare the results in stable and unstable patients. In addition, the definition of stable varied between studies.
In view of the above and the speed and ease of giving adenosine to unstable patients as opposed to the need for and potential risks of anaesthesia in DC cardioversion, it seems sensible to use adenosine as first-line treatment in unstable patients. The evidence indicates that this is the case for both adults and children. However, there has not been a prospective randomised controlled trial comparing the two treatments.Clinical Bottom Line
• There is strong evidence to support the efficacy of using adenosine as first-line treatment in patients who present to emergency departments with unstable PSVT with no increased risk of complications. DC conversion could be used as an alternative treatment when adenosine is not successful.
“Guidance” filter on NHS Evidence – no relevant results
Google advanced search for guidelines originating in the NHS
Luton & Dunstable guideline – no references provided
HDAS www.library.nhs.uk/hdas
• Reconsidering the effectiveness and safety of carotid sinus massage as a therapeutic intervention in patients with supraventricular tachycardia.
Citation: The American journal of emergency medicine, Jun 2015, vol. 33, no. 6, p. 807-809 (June 2015) • Oral verapamil in paroxysmal supraventricular tachycardia recurrence control: A randomized clinical trial Citation: Therapeutic Advances in Cardiovascular Disease, February 2015, vol./is. 9/1(4-9), 1753-9447;1753-9455 (21 Feb 2015) • To decide medical therapy according to ECG criteria in patients with supraventricular tachycardia in emergency department:
Adenosine or diltiazem Citation: International Journal of Clinical and Experimental Medicine, 2015, vol./is. 8/6(9692-9699), 1940-5901 (2015) • Valsalva maneuver for termination of supraventricular tachycardia. Citation: Annals of emergency medicine, Jan 2015, vol. 65, no. 1, p. 27-29 (January 2015) • Modified Valsalva manoeuvre to treat recurrent supraventricular tachycardia: Description of the technique and its successful use
in a patient with a previous near fatal complication of DC cardioversion Citation: BMJ Case Reports, July 2014, 1757-790X (08 Jul 2014) • Adenosine utilization and effect on supraventricular tachycardia in a large, urban EMS system Citation: Canadian Journal of Emergency Medicine, May 2014, vol./is. 16/(S87-S88), 1481-8035 (May 2014)
• Management of supraventricular tachycardias. Citation: British journal of hospital medicine (London, England : 2005), Feb 2014, vol. 75, no. 2, p. C26., 1750-8460 (February 2014) • Identification of the optimum vagal manoeuvre technique for supraventricular tachycardia Citation: Australasian Journal of Paramedicine, 2014, vol./is. 11/1(15), 2202-7270 (2014) • Comparing the efficacy of intravenous adenosine and verapamil in termination of acute paroxysmal supra ventricular
tachycardia Citation: Journal of Ayub Medical College, Abbottabad : JAMC, January 2014, vol./is. 26/1(29-31), 1025-9589 (2014 Jan-Mar) • Randomised evaluation of modified valsalva effectiveness in re-entrant tachycardias (REVERT) study Citation: BMJ Open, 2014, vol./is. 4/3, 2044-6055 (2014) • Irregular supraventricular tachycardia Citation: JAMA Internal Medicine, November 2013, vol./is. 173/21(2001-2003), 2168-6106 (25 Nov 2013) • Are patients admitted to emergency departments with regular supraventricular tachycardia (SVT) treated
appropriately? Citation: Clinical medicine (London, England), Apr 2013, vol. 13, no. 2, p. 146-148, 1470-2118 (April 2013)
• Effectiveness of the Valsalva Manoeuvre for reversion of supraventricular tachycardia. Citation: The Cochrane database of systematic reviews, Jan 2013, vol. 3, p. CD009502. (2013) • Diagnosis and management of supraventricular tachycardia Citation: BMJ (Online), December 2012, vol./is. 345/7887, 1756-1833 (15 Dec 2012) • Management of supraventricular tachycardia using the Valsalva manoeuvre: A historical review and
summary of published evidence Citation: European Journal of Emergency Medicine, December 2012, vol./is. 19/6(346-352), 0969-9546;1473-5695 (December 2012) • Adenosine-induced severe bronchospasm in a patient without pulmonary disease Citation: The American journal of emergency medicine, November 2012, vol./is. 30/9(2082.e3-5), 1532-8171 (Nov 2012) • Adenosine-induced worsening of supraventricular tachycardia Citation: BMJ case reports, 2012, vol./is. 2012/, 1757-790X (2012)
• https://www.clinicalkey.com/#!/topic/supraventricular%2520tachycardia
Keep an eye on social media sources
http://stemlynsblog.org/the-revert-trial/
• Updates of one of papers found in HDAS literature search:“Randomised evaluation of modified valsalva
effectiveness in re-entrant tachycardias (REVERT) study”
• Describes study very recently published in The Lancet & not yet available through HDAS search
http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(15)61485-4.pdf
So what does this MEAN?• Clearly, the findings are pretty impressive. The modified Valsalva is
safe and can cardiovert 43% of patients with SVT. By using the modified Valsalve instead of a standard technique, we could avoid using adenosine in one out of every 5.3 patients treated, which isn’t bad. What’s more, this is a pretty robust trial with no major weaknesses. My only remaining question is whether you need to adopt the Trendellenberg position after the strain or whether being in the supine position all along would be just as effective. I’ve always been taught that the Valsalva manoeuvre is more effective in the supine position. However, based on these data, I’ll certainly be changing my practice and using the modified Valsalva technique as shown in the video.
• It also has some more implications. If we teach patients how to do this themselves, maybe they can self-cardiovert without coming to the ED or using a pill in the pocket. From a patient’s perspective, this could be great.
