Adenosine dose should be less when administered through a central line

Keeping It "Current": A Review of Treatment Options for the Management of Supraventricular Tachycardia

OBJECTIVE

To review treatment options and updates that exist for the management of paroxysmal supraventricular tachycardia (PSVT).

DATA SOURCES

A literature search of PubMed was performed including articles from 1974 to June 2023 using the terms: arrhythmias, adenosine, verapamil, diltiazem, esmolol, propranolol, metoprolol, beta-blockers, amiodarone, PSVT, synchronized cardioversion, methylxanthines, dipyridamole, pediatrics, heart transplant, and pregnancy. Primary literature and guidelines were reviewed.

STUDY SELECTION AND DATA EXTRACTION

Studies were considered if they were available in English and conducted in humans.

DATA SYNTHESIS

PSVT is a subset of supraventricular tachycardia (SVT) that presents as a rapid, regular tachycardia with an abrupt onset and termination. Due to frequent emergency department (ED) visits annually with symptoms of PSVT, appropriate and efficient management of these patients is vital. This review provides an overview of the pathophysiology of PSVT, while also describing the literature behind nonpharmacologic and pharmacologic management of PSVT.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

This review describes new literature regarding the improved success of the modified Valsalva maneuver as a nonpharmacologic therapy in PSVT. In addition, it describes a new technique in administration of adenosine that has improved outcomes, defines dose adjustments needed for drug interactions with adenosine, compares the utilization of nondihydropyridine calcium channel blockers with adenosine, and provides management recommendations for patients in special populations.

CONCLUSIONS

With high annual rates of ED visits for SVT, providers should be aware of the data behind management and modifications of therapy based on patient-specific factors (ie, patient preference, pharmacokinetics/pharmacodynamics, drug interactions, and special populations).

Pathophysiology and treatment of adults with arrhythmias in the emergency department, part 1: Atrial arrhythmias

PURPOSE

This article, the first in a 2-part review, aims to reinforce current literature on the pathophysiology of cardiac arrhythmias and various evidence-based treatment approaches and clinical considerations in the acute care setting. Part 1 of this series focuses on atrial arrhythmias.

SUMMARY

Arrhythmias are prevalent throughout the world and a common presenting condition in the emergency department (ED) setting. Atrial fibrillation (AF) is the most common arrhythmia worldwide and expected to increase in prevalence. Treatment approaches have evolved over time with advances in catheter-directed ablation. Based on historic trials, heart rate control has been the long-standing accepted outpatient treatment modality for AF, but the use of antiarrhythmics is often still indicated for AF in the acute setting, and ED pharmacists should be prepared and poised to help in AF management. Other atrial arrhythmias include atrial flutter (AFL), atrioventricular nodal reentry tachycardia (AVNRT), and atrioventricular reentrant tachycardia (AVRT), which warrant distinction due to their unique pathophysiology and because each requires a different approach to utilization of antiarrhythmics. Atrial arrhythmias are typically associated with greater hemodynamic stability than ventricular arrhythmias but still require nuanced management according to patient subset and risk factors. Since antiarrhythmics can also be proarrhythmic, they may destabilize the patient due to adverse effects, many of which are the focus of black-box label warnings that can be overreaching and limit treatment options. Electrical cardioversion for atrial arrhythmias is generally successful and, depending on the setting and/or hemodynamics, often indicated.

CONCLUSION

Atrial arrhythmias arise from a variety of mechanisms, and appropriate treatment depends on various factors. A firm understanding of physiological and pharmacological concepts serves as a foundation for exploring evidence supporting agents, indications, and adverse effects in order to provide appropriate care for patients.

Pharmacotherapy considerations in advanced cardiac life support

Cardiac arrest and sudden cardiac death remain major causes of mortality. Early intervention has been facilitated by emergency medical response systems and the development of training programs in basic life support and advanced cardiac life support (ACLS). Despite the implementation of these programs, the likelihood of a meaningful outcome in many life-threatening situations remains poor. Pharmacotherapy plays a role in the management of patients with cardiac arrest, with new guidelines for ACLS available in 2005 providing recommendations for the role of specific drug therapies. Epinephrine continues as a recommended means to facilitate defibrillation in patients with pulseless ventricular tachycardia or ventricular fibrillation; vasopressin is an alternative. Amiodarone is the primary antiarrhythmic drug that has been shown to be effective for facilitation of defibrillation in patients with pulseless ventricular tachycardia or fibrillation and is also used for the management of atrial fibrillation and hemodynamically stable ventricular tachycardia. Epinephrine and atropine are the primary agents used for the management of asystole and pulseless electrical activity. Treatment of electrolyte abnormalities, severe hypotension, pulmonary embolism, acute ischemic stroke, and toxicologic emergencies are important components of ACLS management. Selection of the appropriate drug, dose, and timing and route of administration are among the many challenges faced in this setting. Pharmacists who are properly educated and trained regarding the use of pharmacotherapy for patients requiring ACLS can help maximize the likelihood of positive patient outcomes.

Proarrhythmic effects of adenosine: a review of the literature

Adenosine is widely used as an antiarrhythmic agent for the investigation and management of both narrow complex and, less often, broad complex tachycardias. Over the past 10 years or so, reports of severe bradycardias and tachyarrhythmias being induced by this agent have appeared in the literature. As adenosine is increasingly used in emergency departments and indeed outside the hospital setting, a greater awareness of these potential problems is important. In this paper the evidence for such effects is summarised, and the mechanisms involved discussed.

Prehospital management of acute tachyarrhythmias

Arrhythmias are commonly encountered by emergency medical services (EMS) personnel. The potential seriousness of acute symptomatic arrhythmias necessitates thorough up-to-date training of EMS personnel. The three most common acute tachyarrhythmias, not linked to cardiac arrest, that are observed outside the hospital are paroxysmal supraventricular tachycardia (PSVT), atrial fibrillation with rapid ventricular response (RAF), and perfusing ventricular tachycardia (VT). Ideally, these tachyarrhythmias should be operationally defined in a manner that simplifies, particularly for EMS providers, their diagnosis and treatment. The authors recommend referring to these rhythms as regular narrow-complex tachycardia (presumed PSVT), irregularly irregular narrow-complex tachycardia (presumed RAF), or regular wide-complex tachycardia (presumed VT or aberrantly conducted PSVT). Although the value of treatments such as cardioversion is widely understood, the benefit from others, such as lidocaine, is unclear. Current preferences, recommendations, and concerns regarding the treatment of most arrhythmias outside the hospital reflect the dichotomy that sometimes exists between available evidence and actual practice.