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Introduction

  • SVT indicates tachycardia with atrial rates >100 beats per minute

    • a. Traditionally excludes ventricular tachycardias and atrial fibrillation (AF)

    b. Includes: atrial tachycardias, atrioventricular (AV) junctional tachycardias, and AV reentrant

    tachycardias

  • Immediate direct-current (DC) cardioversion is indicated in hemodynamically unstable patients
  • More options available for management of hemodynamically stable patients in SVT of unknown etiology

    • a. First-line: vagal maneuvers

    i. Valsalva maneuver or carotid sinus massage

    b. Second-line (strength of recommendation varies by ACC and ESC)

    i. Adenosine

    ii. IV non-dihydropyridine calcium channel blockers (i.e. diltiazem or verapamil)

    iii. IV beta-blockers (i.e. esmolol or metoprolol)

Clinical Detail

    Adenosine

    Diltiazem

    Verapamil

    Dose

    • 6 mg x 1

    o

    Repeat 12mg q1-2min x2 if

    no effect

    • Can use an initial 12 mg dose of

    caffeine ingested within 4 hours

  • 25mg/kg

    • o

    Repeat with

  • 35 mg/kg IV in

    • 15 minutes if

    needed

  • 5 to 5 mg

    • o

    Repeat with 5-

    10 mg IV

    every 15-30

    minutes

    Administration

    IV bolus as proximal to heart as

    possible with stopcock or diluted in 20-

    30 ml normal saline

    Slow IV push over 2-5 mins

    PK

    Onset: 20-30 sec

    Duration: 10-20 sec

    Onset: ~3 min

    Duration: 3-4 hours

    Onset: 2-7 min

    Duration: 2-5 hours

    Adverse Effects

    Dyspnea, chest tightness, dizziness,

    headache, facial flushing, nausea,

    “electric shock” sensation, transient

Evidence

    Author, year

    Design/

    sample size

    Intervention & Comparison

    Outcome

    Sternbach et

    al. 1986

    Observational;

    n=11

    IV diltiazem 0.25 mg/kg over 5 min

    • Conversion in 64% patients

    • Significant decreased in HR and decreased SBP of 12.4

    mmHg

    McCabe et

    al. 1991

    Observational;

    n=37

    IV adenosine 6 mg rapid push then

    12 mg q2 min x2 if no effect

    • 88% conversion in patients with SVT

    Hood et al.

    1992

    Prospective,

    crossover,

    RCT; n=25

    I1 = IV adenosine administered in

    rapid 40 mcg/kg increments q2 min

    up to 20 mg

    I2 = IV verapamil at 70 mcg/kg

    administered over 5 min and

    repeated q5 min up to 15 mg

    • No significant difference in conversion

    • increased SBP after conversion with adenosine

    • No change in mean SBP after

    conversion with verapamil

    Gauche et

Conclusions

patients. The decrease in systolic blood pressure may not be much of a concern if patients are normotensive. There is

not enough evidence to recommend one agent over in the absence of contraindications to either age

References

    • Brugada et al. European Heart Journal. 2019;00:1-66

    • Page et al. Circulation. 2015;133:506-74

    • Adenosine [Lexi-drugs]

    • Diltiazem [Lexi-drugs]

    • McDowell et al. Acad Emerg Med. 2020;27(1):61-3

    • Sternbach et al. Clin Cardiol. 1986;9:145-49

    • McCabe et al. Ann Emerg Med. 1992;21(4):358-61

    • Hood et al. American Heart Journal. 1992;123:1543-49

    • Gausche et al. Ann Emerg Med. 1994;24(2):183-89

    • Lim et al. Resuscitation. 2002;52:167-74

    • Lim et al. Resuscitation. 2009;80:523-28

    • Alabed et al. Cochrane Database. 2017;10:1-36

Tags:SVT adenosine diltiazem verapamil

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CCB vs Adenosine for SVT- Pharmacy Friday Pearls-PW1. KF1. JP1. Jlp3 (1).pdf