Lisa Harman The Treatment of Paroxysmal Supraventricular Tachycardia

Lisa Harman The Treatment of Paroxysmal Supraventricular Tachycardia (PSVT) and the efficacy of calcium channel blockers verses adenosine in terminating this arrhythmia at The Ottawa Hospital. CCFP-EM Candidate Resident Research Proposal Supervisor: Dr. Gatien Methodologist: Dr. Vaillancourt

Background -PSVT (AVNRT and AVRT) is a common presentation to the ER department. -Current practice as per American Heart Association guidelines is adenosine by IV push. -Historically, however, the initial treatment was an IV bolus of verapamil. This was changed to the current recommendations by the 1992 guidelines due to hypotension from such treatment. -This was challenged by the 2009 RCT by Lim et al comparing the efficacy of IV adenosine to a slower infusion of calcium channel blockers. -They found that IV CCB was more efficacious, longer lasting in preventing rebound SVT and better tolerated. Lim et al. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resus. 2009; 80: 523 -528 .

Based on this RTC and the significant unpleasant sensation associated with the use of adenosine, CCB could be considered the treatment of choice in the ED for PSVT. I am interested to see the proportion of ED physicians at TOH that choose CCBs over adenosine

Record Review Conducting a retrospective record review of 100 charts with discharge Dx of PSVT, matching inclusion criteria to answer the study objectives….

Objectives: Primary Objective: To determine the treatment practices of the physicians at TOH- proportion of patients treated with adenosine vs. CCB.

Objectives Secondary The Objectives success rate of adenosine vs. CCB in converting rhythm to sinus. In the adenosine group, whether a second 12 mg dose was needed In the CCB group, whether a second higher infusion was need In either group whether a second class of medication was needed to convert Or in either group whether cardioversion was needed to convert due to pharmacological failure.

Inclusion Criteria Discharge Dx of PSVT(specifically AVNRT +/orthodromic AVRT- excluding a. fib/flutter and MAT. ) Stable (did not require immediate cardioversion)

Exclusion Criteria Arrhythmia converted spontaneously or with vagal maneuvers Arrhythmia treated by EMS Pregnancy on history In context of decreased GCS, trauma or sepsis Patients with an implanted pacemaker

Table 1 Demographics: Characteristic Age (mean ) Adenosine (n) CCB (n) n n n (%) Initial heart rate (bpm) n ± SD n± SD Duration of arrhythmia (hr) n ± SD Structural heart dz/CHF n (%) CAD n (%) Previous SVT n (%) Previous ablation n (%) Known WPW n (%) Rx for CCB or B-blocker n (%) Bronchospastic lung dz/ asthma n (%) Gender (male)

Primary Outcome 100 Charts of PSVT Adenosine CCB (n)

Secondary Outcomes 100 charts with PSVT Adenosine Sinus (n) CCB Sinus (n) Persistent SVT

Secondary Outcomes Outcome Adenosine CCB Converted by 6 mg dose n (%) NA Converted by 12 mg dose n (%) NA Mean dose to conversion NA n ± SD Received alternate class of medication n (%) Needed cardioversion n (%) n ± SD n (%) (%) Modified LOS (hrs) Proportion with side effects* Success rate * Side effects: hypotension, persistent asystole, a. fib, bronchospasm

Next Steps: REB approval Design data collection tool Design a study protocol

References: Orejarena LA, Vidaillet H Jr. , De. Stefano F, Nordsteom DL, Vierkant RA, Smith PN, Hayes JJ. Paroxysmal supraventricular tachycardia in the general population. J Am Cardiol. 1998; 31 (1): 150. Trohman RG. Supraventricular tachycardia: Implications for the intensivist. Crit Care Med. 2000; 28 (10 Suppl): N 129 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. Resus. 2009; 80: 523 -528. Neumar R, Otto C, Link M, Kronick S, Shuster M, Callaway C, Kudenchuk PJ, Ornato JP, Mc. Nally B, Silvers SM, Passman RS, White RD, Hess, EP, Tang W, Davis D, Sinz E and Morrison LJ. Part 8: Adult Advanced Cardiovascular Life Support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circ. 2010; 122 S 729 -S 767

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