• Carotid sinus massage

• Adenosine: for use when carotid massage fails to convert SVT
  • Possible adverse effects: headache, wheezing, flushing, which will disappear within 45–60 sec; atrial, ventricular, and junctional premature beats; atrial fibrillation in 3% to 5% of cases, which may result in serious problems for patients with accessory pathways
  • An external defibrillator should be readily available when adenosine is administered
  • Dose: initial dose: rapid bolus of 6 mg I.V., followed by a saline flush; if necessary, a 12 mg dose and finally an 18 mg dose can be given
• Metoprolol (5 mg I.V.) or verapamil (0.1 mg/kg I.V.) for patients who fail to respond to adenosine

Long-term Therapy

• Associated with frequent recurrences and adverse effects

• Beta blockers
• Sotalol
  • Common side effects: torsade de pointes, heart failure, bradycardia, exacerbation of chronic obstructive or bronchospastic lung disease
  • Adjust dose for renal function and QT-interval response during in-hospital initiation phase
  • Dose: 240–320 mg/day
  • Cost/mo: $138
• Calcium channel blockers (verapamil, diltiazem)
• Digoxin
  • Dose: 0.1 mg/day
  • Cost/mo: $9
• Antiarrhythmic agents: for patients without structural cardiac disease; more effective than beta blockers and calcium channel blockers, but with 25% to 35% recurrence rates
• Amiodarone
  • Common side effects: photosensitivity, pulmonary toxicity, polyneuropathy, GI upset, bradycardia, torsade de pointes (rare), hepatic toxicity, thyroid dysfunction
  • Dose: 100–400 mg/day
  • Cost/mo: $94
• Disopyramide
  • Common side effects: torsade de pointes, heart failure, glaucoma, urinary retention, dry mouth
  • Dose: 400–750 mg/day
  • Cost/mo: $84
• Dofetilide
  • Common side effect: torsade de pointes
  • Dose: 500–1,000 mg/day
  • Cost/mo: N/A
• Flecainide
  • Common side effects: ventricular tachycardia, heart failure, enhanced AV nodal conduction (conversion to atrial flutter)
  • Dose: 200–300 mg/day
  • Cost/mo: $115
• Procainamide
  • Common side effects: torsade de pointes, lupuslike syndrome, GI symptoms
  • Dose: 1,000–4,000 mg/day
  • Cost/mo: $59
• Propafenone
  • Common side effects: ventricular tachycardia, heart failure, enhanced AV nodal conduction (conversion to atrial flutter)
  • Dose: 490–900 mg/day
  • Cost/mo: $198
• Quinidine
  • Common side effects: torsade de pointes, GI upset, enhanced AV nodal conduction
  • Dose: 600–1,500 mg/day
  • Cost/mo: $67
• Single-dose agents for p.r.n. use: diltiazem, 120 mg, or propranolol, 80 mg; p.r.n. dosing regimens are used with caution and only after efficacy and safety have been established for the individual patient under ECG monitoring

Nonpharmacologic

• Catheter ablation
  • Procedure of choice for patients in whom drug therapy fails and those with milder symptoms who prefer to avoid long-term drug therapy
  • Success rate > 96%
  • AV block occurs in ~ 1% of patients

Kwaku KF, et al: Card Electophysiol Rev 6:414, 2002

Jackman WM, et al: N Engl J Med 327:313, 1992

October 2004

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