HOW TO STOP

PAROXYSM OF
SVT AND AF AT
HOME AND IN
HOSPITAL
- JOISY ALOOR
6TH YEAR
 DEFINITION OF PAROXYSMAL SVT

▪ The term ‘SVT’ literally indicates tachycardia [atrial rates

>100 beats per minute (b.p.m.) at rest], the mechanism of
which involves tissue from the His bundle or above.
▪ Paroxysmal SVT (pSVT) describes an SVT with abrupt onset
and offset – characteristically seen with re-entrant
tachycardias involving the AV node such as AVNRT or
atrioventricular re-entry tachycardia (AVRT).
 WHAT ARE THE SYMPTOMS OF PSVT?

 PSVT is often misdiagnosed as a panic attack. Symptoms include:

• A regular but racing heartbeat of 120 to 230 beats per minute that
starts and stops abruptly
• Palpitations
• Fatigue
• Dizziness
• Syncope
• Chest pain
 TREATMENT OF SVT AT HOME

▪ The goal is to slow down the heart's pace and make sure nothing more serious
happens. Some possible treatments include:
1. Vagal Maneuvers:
• This method uses easy exercises to spark the vagus nerve, which helps set the
beating of the heart.
• Vagal manoeuvres can be used to terminate an episode of narrow QRS SVT. The
effectiveness of conventional vagal manoeuvres in terminating SVT, when correctly
performed, has been reported as between 19 and 54%.
• Begin by bearing down as if you were sitting on a toilet. Close your mouth, clamp
your nose shut, and exhale. If in a doctor's office or hospital, you might get the
same effect by blowing into a tube. This is also called a “Valsalva maneuver.”
2. Other Quick Remedies:
▪ If the vagal maneuvers don’t work, consider:
• Blowing into a closed fist
• Coughing
• Holding breath for a few seconds
• Putting cold water on the face
 TREATMENT OF SVT AT HOSPITAL

▪ If these maneuvers are not effective, if the arrhythmia causes severe

symptoms, or if the episode lasts more than 20 minutes, people are
advised to seek medical intervention to stop the episode.
▪ Doctors can usually stop an episode promptly by giving an intravenous
injection of a drug, usually adenosine or verapamil. Rarely, drugs are
ineffective, and cardioversion (delivery of an electrical shock to the
heart) may be necessary.
▪ Acute management of paroxysmal supraventricular tachycardia (PSVT)
includes controlling the rate and preventing hemodynamic collapse. If
the patient is hypotensive or unstable, immediate cardioversion with
sedation must be performed.
▪ If vagal maneuvers are not successful, adenosine can be used in increasing
doses.
▪ If adenosine does not work, atrioventricular (AV) nodal blocking agents like
calcium channel blockers or beta-blockers should be used, as most patients who
present with PSVT have AV nodal reentrant tachycardia (AVNRT) or AV reentrant
tachycardia (AVRT). These arrhythmias depend on AV nodal conduction and
therefore can be terminated by transiently blocking this conduction.
▪ Adenosine Dosage Forms & Strengths (Adult):
▪ Injectable solution: 6mg/2mL prefilled syringe
12mg/4mL prefilled syringe
SLOW-FAST (TYPICAL) AVNRT:
ECG Features:
Narrow complex tachycardia at ~ 150 bpm
No visible P waves
There are pseudo R’ waves in V1-2

https://litfl.com/supraventricular-
tachycardia-svt-ecg-library/
Pseudo R’ waves in V1-2
▪ Electrical cardioversion is the most effective method for restoring
sinus rhythm. Synchronized cardioversion starting at 50J can be used
immediately in patients who are hypotensive, have pulmonary edema,
have chest pain with ischemia, or are otherwise unstable.
▪ Patients who require cardioversion, are unstable, and have comorbid
illnesses should be admitted to the hospital. Patients who are young,
healthy, and asymptomatic may be discharged and advised to have a
follow-up examination with their primary physician or cardiologist. If
the patient is having more frequent episodes of paroxysmal SVT and
medical therapy is not successful or desired, then radiofrequency
catheter ablation should be proposed.
 CONSULTATIONS

▪ A cardiologist should be consulted for patients with frequent

episodes of paroxysmal SVT, syncope, and/or preexcitation
syndromes. Consultation with a cardiologist should also be
obtained for patients in whom medical management has
failed.
▪ An electrophysiologist should be consulted for patients
considered for radiofrequency catheter ablation. Pediatric
patients should be referred to a pediatric electrophysiologist.
a. Transfer
▪ Patient transfer to a center with radiofrequency catheter ablation is reasonable if
this therapy is planned. Alternatively, patients can be discharged home and
scheduled for outpatient procedures. Exceptions include patients with syncope,
profound symptoms, or preexcited atrial fibrillation or atrial flutter.
b. Monitoring
▪ Patients treated medically should be monitored regularly. Patients cured with
radiofrequency catheter ablation are typically seen once in a follow-up examination
following the procedure, then as needed for recurrent symptoms.
c. Dietary/ Lifestyle Changes
 DEFINITION OF PAROXYSMAL AF

▪ Paroxysmal atrial fibrillation occurs when a rapid, erratic

heart rate begins suddenly and then stops on its own within 7
days. It is also known as intermittent A-fib and often lasts for
less than 24 hours.
▪ The American Heart Association (AHA) estimate that 2.7
million American people live with some form of A-fib. The
likelihood of experiencing paroxysmal A-fib increases with
age.
 SYMPTOMS

▪ Heart palpitations
▪ Chest pain or pressure
▪ Delirium
▪ Dizziness
▪ Fatigue
▪ Dyspnea
▪ Not able to do moderate to intense activity
 TREATMENT OF AF AT HOME

1. Taking slow deep breaths: sit down and place one hand on the
stomach.
▪ Inhale deeply through the nose, all the way into the stomach, for a
count of 4 seconds.
▪ Do this to slowly fill up the lungs with air gradually, until they are
completely filled.
▪ Hold this breath for a moment, before exhaling through the mouth for
the same amount of time.
2. Drinking cold water: Slowly drinking a glass of cold water
can help steady the heart rate. This tip is especially useful for
those whose A-fib episode has been brought on by
dehydration.
3. Aerobic activity: Some people report feeling better after
exercising. A 2002 case study, published in the New England
Journal of Medicine, found that a 45-year-old athlete with
paroxysmal A-fib stopped symptoms by engaging in a low
impact aerobic activity. In this case study, the athlete used an
elliptical machine or a cross-country skiing machine.
4. Yoga: Is known to relax those who practice it by focusing on
the breathing. This could be beneficial for those with A-fib —
both to stop a current episode and as a preventative
technique.
5. Biofeedback training: Biofeedback techniques can have a
calming effect on people during an A-fib episode. Biofeedback
involves training the mind to control the body’s responses to
external and internal triggers. It can improve a person’s
control of their autonomic nervous system functions, which
can stabilize the heart’s rhythm.
6. Vagal maneuvers: These techniques may stop a paroxysmal
A-fib episode. Examples of such maneuvers include coughing,
or engaging the muscles as if having a bowel movement.
7. Exercise
8. Healthy diet: It is also important to stay hydrated throughout the day to prevent A-
fib episodes and other health concerns.
Alcohol: Research suggests that even moderate drinking can cause A-fib episodes in
those with heart disease or diabetes. People with A-fib should drink no more than
two alcoholic beverages on any day.
Caffeine: Research on the benefits or risks of caffeine for people with A-fib is mixed.
While moderate amounts of coffee or tea may be fine, it may be best to avoid
excessive quantities of caffeine.
9. Healthy weight, less stress and no smoking and maintaining BP.
 TREATMENT OF AF AT HOSPITAL

1. Digoxin (Cardiac glycoside): IV: 8-12 mcg/kg (0.008-0.012 mg/kg) total loading dose;
administer 50% initially; then may cautiously give 1/4 the loading dose 6-8hr twice.
2. Chemical cardioversion: Heart rhythm control through medications such as sodium,
calcium and potassium channel blockers. Main drug for cardioversion:
▪ Amiodarone Dosage Forms & Strengths:
• Injectable solution: 50mg/mL
150mg/100mL (Nexterone)
360mg/200mL (Nexterone)
• Tablet: 100mg, 200mg, 400mg.
▪ Blood clot and stroke prevention: To lower the chances of having this condition.
Aspirin, heparin, warfarin, rivaroxaban is used.
▪ E.g.: Aspirin 325 mg
500 mg, every 4-6 hours.
▪ Surgery and Other Procedures: If medications don't get AFib under control, the
doctor might recommend one of these:
▪ Electrical cardioversion: Electrical cardioversion involves receiving an electric shock
to the outside of the chest wall to restore the normal rhythm of the heart. This will
take place under general anesthetic. As with defibrillation, electrical cardioversion
can help reset a person’s heart rhythm. The only difference is that electrical
cardioversion usually uses lower levels of electricity than defibrillation. For this
reason, it may be necessary to deliver multiple shocks.
• Catheter ablation: Catheter ablation is an option for people whose medications
are no longer effective and those for whom electrical cardioversion was not
effective or possible.
• The procedure involves inserting a thin, flexible tube called a catheter into the
blood vessels and guiding it toward the heart. Catheter ablation aims to destroy
the faulty tissues responsible for the incorrect signals and irregular heart rhythm.
• The surgery achieves this using one of three methods:
radiofrequency
laser
freezing
▪ Maze surgery:
▪ Surgeons will perform full “maze” surgeries when people with A-fib have open-
heart surgery, such as a heart bypass or valve replacement. The reason for its
name is the pattern that results from the surgery.
▪ During the procedure, the surgeon will make several cuts in a person’s heart to
create scar tissue to interrupt the erratic electrical signals that rise to A-fib.
▪ Around 90%Trusted Source of people will be free from A-fib following maze
surgery, according to one 2011 study.
▪ Mini-maze surgery is another option for those who are not candidates for open-
heart surgery. This is a minimally invasive version of the full maze surgery.
Heart failure and AF coincide in many patients. They are
linked by similar risk factors and share a common pathophysiology.
▪ Pacemaker: A pacemaker is a small device that a surgeon implants under the skin in
the upper chest, near the collarbone. It has wires that tunnel into the heart.
• Pacemakers do not treat A-fib, instead using electrical pulses to monitor and regulate
heart rhythm. A person may require a pacemaker after certain types of ablation, or
when a heart medication causes an excessively slow heartbeat.
• Before fitting the pacemaker, the tissue of the atrioventricular node will be damaged.
In a way, the surgeon is cutting the body’s own electrical cables and replacing them
with a pacemaker, which a cardiologist can easily program to prevent fast heart
rhythms. The pacemaker will then transmit regular heart rhythms.
▪ Treatment with metformin seems to be associated with a decreased long-term risk of
AF in diabetic patients and may even be associated with a lower long-term stroke risk.
ATRIAL FIBRILLATION WITH NORMAL
VENTRICULAR RATE ECG