Common Types of Supraventricular Tachycardia: Diagnosis ... https://www.aafp.org/pubs/afp/issues/2023/0600/supraventri...

Common Types of Supraventricular Tachycardia:

Diagnosis and Management
MUNIMA NASIR, MD, ASHLEY STURTS, DO, AND ADAM STURTS, DO

 Am Fam Physician. 2023;107(6):631-641

 Patient information: See related handout on supraventricular tachycardia
(https://www.aafp.org/pubs/afp/issues/2023/0600/patient-information-supraventricular-
tachycardia.html).

 This clinical content conforms to AAFP criteria for CME.

 Author disclosure: No relevant financial relationships.
Supraventricular tachycardia (SVT) is an abnormal rapid cardiac rhythm that involves atrial or
atrioventricular node tissue from the His bundle or above. Paroxysmal SVT, a subset of
supraventricular dysrhythmias, has three common types: atrioventricular nodal reentrant
tachycardia, atrioventricular reentrant tachycardia, and atrial tachycardia. Presenting
symptoms may include altered consciousness, chest pressure or discomfort, dyspnea,
fatigue, lightheadedness, or palpitations. Diagnostic evaluation may be performed in the
outpatient setting and includes a comprehensive history and physical examination,
electrocardiography, and laboratory workup. Extended cardiac monitoring with a Holter
monitor or event recorder may be needed to confirm the diagnosis. Acute management of
paroxysmal SVT is similar across the various types and is best completed in the emergency
department or hospital setting. In patients who are hemodynamically unstable, synchronized
cardioversion is first-line management. In those who are hemodynamically stable, vagal
maneuvers are first-line management, followed by stepwise medication management if
ineffective. Beta blockers and/or calcium channel blockers may be used acutely or for long-
term suppressive therapy. When evaluating patients for paroxysmal SVTs, clinicians should
have a low threshold for referral to a cardiologist for electrophysiologic study and appropriate
intervention such as ablation. Clinicians should use a patient-centered approach when
formulating a long-term management plan for atrioventricular nodal reentrant tachycardia.
Catheter ablation has a high success rate and is recommended as the first-line method for
long-term management of recurrent, symptomatic paroxysmal SVT, including Wolff-Parkinson-
White syndrome.

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Supraventricular tachycardia (SVT) refers to tachycardia (i.e., atrial or ventricular rate higher than
100 beats per minute at rest) that involves tissue from the His bundle or above.1 Classically, the
term paroxysmal SVT includes most tachycardias, except ventricular tachycardia and atrial
fibrillation, with paroxysmal SVT comprising a subset that is characterized by a regular
tachycardia having abrupt onset and termination. The prevalence of paroxysmal SVT is 2.29 per
1,000 people in the general population.1,2 Although paroxysmal SVT is a common reason for
patients of all ages to visit a physician or emergency department, middle-aged women are most
often affected, accounting for an estimated 62% of all cases.2,3

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating Comments

Vagal maneuvers are recommended to terminate B Consensus guidelines from

SVT in hemodynamically stable patients.1,11,15,16 the ACC and ESC; meta-
analysis evaluating a
modified Valsalva maneuver;
Cochrane review with
insufficient evidence

If vagal maneuvers fail, intravenous adenosine C Consensus guidelines from

may be used in hemodynamically stable patients the ACC and ESC
as a therapeutic agent in narrow complex
tachycardia or as a diagnostic and therapeutic
agent in undifferentiated wide complex
tachycardia without preexcitation.1,11

Brugada criteria can be used to distinguish C Consensus guidelines from

between SVT with aberrant conduction and the ACC
ventricular tachycardia.1

Catheter ablation is generally recommended for C Consensus guidelines from

recur rent, symptomatic SVT.1,11 the ACC and ESC

ACC = American College of Cardiology; ESC = European Society of Cardiology; SVT = supraventricular
tachycardia.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented

evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For
information about the SORT evidence rating system, go to https://www.aafp.org/afpsort

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(https://www.aafp.org/afpsort).

Paroxysmal SVT is classified based on the location of the reentrant circuit. The most common
types are atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, and
atrial tachycardia, which are illustrated in Figure 1.4 A high index of suspicion is needed in the
primary care setting because paroxysmal SVT commonly occurs without underlying cardiac
disease.

FIGURE 1A

In normal sinus rhythm, impulses from the sinoatrial node travel through the conduction system and are
delayed by the atrioventricular node, creating the standard PR interval.

Adapted with permission from Colucci RA, Silver MJ, Shubrook J. Common types of supraventricular tachycardia:
diagnosis and management. Am Fam Physician. 2010;82(8):944.

FIGURE 1B

Atrioventricular nodal reentrant tachycardia is the most common type of paroxysmal supraventricular
tachycardia. In this type, the standard conduction through the atrioventricular node pairs with a fast
retrograde conduction through the atrioventricular node. Most often, P waves are not seen, but
occasionally a retrograde P wave may be visible early after the QRS complex as a pseudo–S wave in lead II
or a pseudo–R wave in lead V1.

Adapted with permission from Colucci RA, Silver MJ, Shubrook J. Common types of supraventricular tachycardia:
diagnosis and management. Am Fam Physician. 2010;82(8):944.

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FIGURE 1C

In atrioventricular reentrant tachycardia, there is an accessory pathway that distributes ventricular signals
back to the atria. If visible, P waves in atrioventricular reentrant tachycardia are most often after the QRS
complex.

Adapted with permission from Colucci RA, Silver MJ, Shubrook J. Common types of supraventricular tachycardia:
diagnosis and management. Am Fam Physician. 2010;82(8):944.

FIGURE 1D

In atrial tachycardia, a focus within the atria provides a rapid signal that overwhelms the signal from the
sinoatrial node. Atrial tachycardia typically produces normal PR intervals because the delay from the
atrioventricular node is not affected. The morphology and axis of the P wave depend on the location of the
atrial focus.

Adapted with permission from Colucci RA, Silver MJ, Shubrook J. Common types of supraventricular tachycardia:
diagnosis and management. Am Fam Physician. 2010;82(8):944.

Causes of Paroxysmal SVT

Paroxysmal SVT is usually not associated with structural heart disease, especially in young
people. Cardiac comorbidities such as coronary artery disease, congestive heart failure,
cardiomyopathy, and valvular heart disease are more common in patients with paroxysmal SVT
who are older than 50 years.2 Uncommon cardiac causes include congenital/structural heart

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disease; myocardial scarring from diseases such as sarcoidosis and tuberculosis; prior atrial
surgeries; primary electrical disorders such as long QT syndrome; and presence of accessory
pathways, including familial preexcitation syndrome.2 Reentrant tachycardias can also be
triggered by hyperthyroidism, electrolyte disturbances, excessive intake of caffeine or alcohol,
and use of certain medications or recreational drugs. Possible triggers are listed in Table 1.

TABLE 1.

Triggers for Supraventricular Tachycardia

Types of Paroxysmal SVT

ATRIOVENTRICULAR NODAL REENTRANT TACHYCARDIA

The most common type of paroxysmal SVT is atrioventricular nodal reentrant tachycardia,
accounting for about two-thirds of all cases.5 This type can present at any age but is more
common in young adults and in women.5,6 Atrioventricular nodal reentrant tachycardia is caused
by a reentry circuit formed by the atrioventricular node and perinodal atrial tissue.7 It typically
involves dual electrical pathways, one slow and one fast. An episode of typical atrioventricular
nodal reentrant tachycardia may be triggered by a critically timed premature atrial contraction
that leads to retrograde conduction up the fast pathway from the atrioventricular node to the
atria. The retrograde impulse depolarizes the atria forming a repetitive, self-propagating circuit

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with a rapid and regular ventricular response. Because retrograde atrial activation and antero-
grade ventricular activation occur almost simultaneously, P waves are usually hidden on
electrocardiography (ECG). However, if there is relatively delayed retrograde conduction, P waves
may be seen as part of the terminal QRS complex (retrograde P waves) forming a pseudo–R
deflection in lead V1 and a pseudo–S wave in the inferior leads.

ATRIOVENTRICULAR REENTRANT TACHYCARDIA

Atrioventricular reentrant tachycardia is the second most common type of paroxysmal SVT
overall (approximately 30% of all cases) and the most common type in children.8 This type is a
reentrant circuit tachycardia mediated by an accessory pathway. The atrioventricular accessory
pathway consists of shared proximal (atrial) and distal (ventricular) tissues that form a reentrant
circuit with the normal atrioventricular conduction system when triggered by a premature atrial
or ventricular beat. The accessory pathway may conduct an electrical impulse in the anterograde
or retrograde direction. Pathologic anterograde conduction through the accessory pathway that
reaches the ventricle before the impulse through the atrioventricular node causes ventricular
preexcitation. A delta wave (slurring of the QRS complex) is present on ECG in most cases of
anterograde accessory tracts (Figure 23).

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Author Information
MUNIMA NASIR, MD, FAAFP, is an associate professor in the Department of Family and
Community Medicine at Milton S. Hershey Medical Center, Hershey, Pa.

ASHLEY STURTS, DO, is a fellow physician in the Department of Family and Community
Medicine at Pennsylvania State University, Penn State Health, State College.

ADAM STURTS, DO, is a resident physician in the Department of Internal Medicine at Milton S.

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Hershey Medical Center.

Address correspondence to Munima Nasir, MD, FAAFP, University Physicians Group – Middletown,
3100 Schoolhouse Rd., Middletown, PA 17057 (email: mnasir@pennstatehealth.psu.edu
(mailto:mnasir@pennstatehealth.psu.edu)). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

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