Acute Management of Refractory and Unstable Pediatric Supraventricular Tachycardia
Jonathan Lewis1, Gaurav Arora2, Dana L Tudorascu3
1Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh, Pittsburgh, PA.
Insights
Young children with supraventricular tachycardia (SVT) respond less effectively to adenosine. Infants with SVT are more likely to experience adenosine-refractory SVT, requiring alternative management strategies.
Area of Science:
- Pediatric Cardiology
- Electrophysiology
- Critical Care Medicine
Background:
- Supraventricular tachycardia (SVT) is a common arrhythmia in children.
- Adenosine is a first-line treatment for acute pediatric SVT.
- Infants and unstable patients present unique management challenges.
Purpose of the Study:
- To analyze the management of acute pediatric SVT.
- To focus on infants, adenosine-refractory SVT, and unstable SVT.
- To identify age as a risk factor for SVT treatment outcomes.
Main Methods:
- Retrospective cohort study of 179 pediatric SVT episodes (2003-2012).
- Analysis of adenosine efficacy and refractory SVT rates.
- Logistic regression to assess age as a risk factor.
Main Results:
- Adenosine was effective in 56% of first doses and 50% of second doses.
- 15% of SVT episodes were refractory to adenosine.
- Infants had significantly higher rates of refractory SVT (P=.01).
- Adenosine response increased with age (OR 1.13).
- Unstable SVT (13 episodes) was managed with adenosine, antiarrhythmics, and rarely cardioversion.
Conclusions:
- Younger age correlates with reduced adenosine efficacy and increased refractory SVT.
- Medical management may precede cardioversion in unstable SVT.
- Synchronized cardioversion is infrequently utilized for acute pediatric SVT.
Objective:
To characterize the management of acute pediatric supraventricular tachycardia (SVT), placing special emphasis on infants, patients refractory to adenosine (refractory SVT), and patients with hypotension, poor perfusion, or altered mental status (unstable SVT).
Study Design:
Retrospective cohort study of patients 0-18 years of age without congenital heart disease who presented to our pediatric hospital from January 2003 to December 2012 for the treatment of acute SVT. Multiple logistic regression was applied to identify whether age was a risk factor for different SVT therapies. Model fit and residuals also were examined.
Results:
We identified 179 episodes for SVT. First dose of adenosine was effective in 72 (56%) episodes, and a second dose was effective in 27 of 54 (50%) episodes, leaving 27 (15%) episodes with refractory SVT. The response to the first dose of adenosine increased proportionally with age (OR 1.13, 95% CI 1.05-1.2). Only 1 of 17 episodes in infants responded to the first dose of adenosine. Refractory SVT was more frequent in infants vs older children (χ2 = 5.9 [1 df], P = .01). Unstable SVT was present in 13 episodes and was treated with adenosine and antiarrhythmics. Synchronized cardioversion was performed on 3 patients, 2 patients with unstable SVT, and 1 with refractory SVT.
Conclusion:
In children with SVT, young age is associated with decreased response to the first dose of adenosine and increased odds of adenosine-refractory SVT. In the treatment of unstable SVT, medical management with various antiarrhythmics before cardioversion may have a role in a subset of patients. Synchronized cardioversion rarely is performed for acute SVT.
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