Page 31 - Delaware Medical Journal - July/August 2019
P. 31
CASE REPORT
higher than commonly used in current clinical practice.8 The 2015 ACC/AHA/ HRS guidelines list oral digoxin as a reasonable third-line treatment option
for long-term management of SVT. Intravenous digoxin is not included in the treatment recommendations for the acute management of SVT, and there is little evidence to support its use for treatment in the acute setting.
NON-PHARMACOLOGICAL TREATMENTS
An EP study with catheter ablation
with refractory SVT. An EP study involves placing multielectrode catheters in the heart to perform pacing and programmed electrical stimulation (+/- pharmacological provocation) to precisely diagnose the mechanism of the SVT. Cardiac mapping is performed during the EP study to identify the site of origin of a dysrhythmia or areas of critical conduction to allow targeting
of ablation. Many facilities do not have
an electrophysiologist on call 24/7, so transferring a patient to a facility capable of performing an emergent EP study is a reasonable option for patients with SVT refractory to pharmacological therapy and signs of cardiovascular deterioration.
TACHYCARDIA-INDUCED CARDIOMYOPATHY
One of the severe complications of any untreated tachydysrhythmia is tachycardia- induced cardiomyopathy (TIC). TIC is
as a reversible impairment of ventricular function induced by a persistent tachydysrhythmia. Treatment is focused on cessation of the tachycardia, which typically leads to clinical improvement and recovery of ventricular function. There are case reports of extracorporeal membrane
oxygenation (ECMO) use in patients with cardiogenic shock due to TIC,9,10 including one patient who underwent successful ablation while on ECMO.11 Most of these cases involved neonatal or pediatric patients, and the use of ECMO in adults with TIC is understudied.
CONCLUSION
Most patients presenting to the ED in SVT can be adequately managed with maneuvers and adenosine. Second-line treatment options include intravenous calcium channel blockers, beta blockers, refractory SVT and should be pursued urgently in patients with persistent tachycardia who are at risk for TIC and cardiogenic shock.
CONTRIBUTING AUTHORS
■ VITALIY BELYSHEV, MD was a third-year Emergency Medicine resident at Christiana Care Health System upon completion of this case report and is currently an Emergency Medicine Ultrasound Fellow at Carolinas Medical Center.
■ JEREMY BERBERIAN, MD, is a board-certified Emergency Medicine physician working for Doctors for Emergency Services and practicing at Christiana Care Health System. He is the Associate Director of Resident Education for the Emergency Medicine Residency Program at Christiana Care Health System.
■ JONATHAN McGHEE, DO, is a board-certified Emergency Medicine physician working for Doctors for Emergency Services and practicing at Christiana Care Health System. He is one
of the Associate Program Directors for the Emergency Medicine Residency Program at Christiana Care Health System and a former President of the Delaware Chapter of the American College of Emergency Physicians.
REFERENCES
1. Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2016;67(13):e27-e115.
2. Lim SH, Anantharaman V, Teo WS, Chan YH. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation. 2009;80(5):523- 528.
3. Alabed S, Sabouni A, Providencia R, Atallah E, Qintar M, Chico TJ. Adenosine versus intravenous calcium channel antagonists for supraventricular tachycardia. Cochrane Database Syst Rev. 2017;10:CD005154.
4. Gupta A, Naik A, Vora A, Lokhandwala Y. Comparison of efficacy of intravenous diltiazem and esmolol in terminating supraventricular tachycardia. J Assoc Physicians India. 1999;47(10):969-972.
5. Hamer AW, Strathmore N, Vohra JK, Hunt VD. Oral flecainide, sotalol, and verapamil for the termination of paroxysmal supraventricular tachycardia. Pacing Clin Electrophysiol. 1993;16(7 Pt 1):1394-1400.
6. Anderson JL, Platt ML, Guarnieri T, Fox TL, Maser MJ, Pritchett ELC. Flecainide acetate for paroxysmal supraventricular tachyarrhythmias. Am J Cardiol. 1994;74(6):578-584.
7. Ekiz A E al. Flecainide as first-line treatment for fetal supraventricular tachycardia. - PubMed - NCBI. www.ncbi.nlm.nih.gov/ pubmed/28114840. Accessed November 15, 2017.
8. Winniford MD, Fulton KL, Hillis LD. Long- term therapy of paroxysmal supraventricular tachycardia: a randomized, double-blind comparison of digoxin, propranolol and verapamil. Am J Cardiol. 1984;54:1138–9.
9. Lee JW, Ahn HJ, Yoo YH, Lee JW, Kim SW, Choi SW. Extracorporeal CPR and intra-aortic balloon pumping in tachycardia-induced cardiomyopathy complicating cardiac arrest. Am J Emerg Med. 2017;35(8):1208.e5-e1208.e7.
10. Salerno JC, Seslar SP, Chun TUH, et al. Predictors of ECMO support in infants with tachycardia-induced cardiomyopathy. Pediatr Cardiol. 2011;32(6):754-758.
11. Cheruvu C, Walker B, Kuchar D, Subbiah RN. Successful ablation of incessant AV reentrant tachycardia in a patient on extracorporeal membrane oxygenation. Heart Lung Circ. 2014;23(1):e12-e15.
Del Med J | July/August 2019 | Vol. 91 | No. 4
175
