Pediatric

Supraventricular
Tachycardia
Emily Letsinger, PharmD
PGY1 Pharmacy Resident
Objectives

• Recall potential non-pharmacologic treatment options for the

management of supraventricular tachycardia (SVT)

• Describe appropriate dosing strategies for adenosine for SVT

• Evaluate the efficacy and safety of pharmacologic treatment

options for the management of adenosine-resistant SVT

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Meet ED
ED - Initial Presentation, Subjective

CC: ED is a 9 mo who was diagnosed with Wolff-Parkinson-White (WPW)

syndrome who presented to the ED in supraventricular tachycardia (SVT)

PMH: WPW, no surgical history

HPI:
• SVT was detected at home by Owlet
• First episode of SVT since birth
• SVT started around 2pm and mom attempted vagal maneuvers at home
(turn patient upside down and ice) which terminated the tachycardia.
Patient went back into SVT around 5pm and the same vagal maneuvers
were attempted without resolution.
• Recently diagnosed with pneumonia and completed a course of cefdinir

Home medications: Propranolol 20 mg/5 mL 6 mg (0.6 mg/kg) PO Q8H

4
Pediatric SVT Clinical Significance

Incidence
• SVT is the most common rhythm disturbance in
children
• Occurs in ~1 in 250 otherwise healthy children

Epidemiology:
• Approximately 50% of children with SVT will present
with their first episode in the first year of life
• In infants, spontaneous resolution occurs in > 90% by 1
year of age

Genetics:
• ~7% of patients with SVT have a first-degree relative
with documented SVT
5
Salerno JC, et al. Arch Pediatr Adolesc Med 2009.
Defining Supraventricular Tachycardia

SVT is a narrow, complex

tachycardia that requires atrial
tissue or the atrioventricular node
as an integral part of the
arrhythmia substrate

Typically caused by the presence

of an additional/accessory
electrical connection between the
atrium and ventricle that causes
reentry

6
Salerno JC, et al. Arch Pediatr Adolesc Med 2009.
Signs and Symptoms of SVT

Infants and Young Children Older Children and Adolescents

HR: ≥ 220 beats/minute HR: ≥ 180 beats/minute

● Cyanosis
● Palpitations
● Pallor
● Shortness of breath
● Irritability
● Chest pain
● Trouble with feedings
● Dizziness
● Tachypnea
● Syncope
● Sweating

7
Topjian AA, et al. Circulation 2020.
Salerno JC, et al. Arch Pediatr Adolesc Med 2009.
Diagnosis of SVT

Gold standard: Recording a heart rhythm strip during symptoms

• ECG
• Event recorders
• 24-hr ambulatory monitoring

8
Salerno JC, et al. Arch Pediatr Adolesc Med 2009.
ED - Initial Presentation, ED Workup

Weight: 9.6 kg

Vitals:
• HR: 240-250 (baseline 80-100)
• Normal BP
• Temperature: 100.2℉

Physical Exam:
• Well perfused, warm to touch
• Fussy and crying

Tests:
• Telemetry: SVT Hemodynamically
• Labs: Not obtained stable
9
 PALS
Guidelines:
Tachycardia
with a Pulse
Non-Pharmacologic Therapy

Synchronized Cardioversion
• Treatment of choice for hemodynamically
unstable SVT
• Consider sedation prior to cardioversion

Vagal Maneuvers
• Ice
• Headstand/turn upside-down
• Coughing
• Blow through a straw
• Bearing down

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 PALS
Guidelines:
Tachycardia
with a Pulse
ED - Initial Management of SVT

4/4/22 1900 1904 1908 1934 1934

Vagal Maneuvers ✔

Adenosine 0.2 mg/kg ✔

Adenosine 0.3 mg/kg ✔

Adenosine 0.3 mg/kg ✔

Procainamide 96 mg (10 mg/kg) ✔

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Pharmacologic Therapy &
Supportive Literature
Adenosine

Mechanism of Slows conduction time through the AV node, interrupting the re-entry
Action pathways through the AV node

1st dose: 0.1 mg/kg IV/IO (max dose of 6 mg)

2nd dose: 0.2 mg/kg IV/IO (max dose of 12 mg)
Dose
**Doses of 0.3 mg/kg and 0.45 mg/kg have been noted in literature

Rapid IV push
● Half-life: < 10 seconds
Administration ● Inject into most proximal injection site or central venous line
● Utilize stopcock method
● Dose <1 mL: dilute with NS to reach a minimum total volume of 1mL

Adverse Effects:
● Chest pain/pressure
Clinical Pearls ● Dyspnea
● Facial flushing
● Transient decrease in blood pressure
15
Topjian AA, et al. Circulation 2020.
Adenosine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL.
Adenosine - Supportive Literature
Use of Adenosine in the Treatment of Supraventricular Tachycardia in a Pediatric Emergency Department

Study Design ● Retrospective: January 2007 to December 2011

Sample Size ● 44 episodes in 26 patients

● Inclusion: < 14 years old, presented to ED with SVT

Patients ● Exclusion: Diagnosis of SVT at another center where SVT had reverted to NSR

● Vagal maneuvers (cold bag, Valsalva maneuvers) while IV access was obtained
Interventions ● Adenosine at incremental doses of 0.1, 0.2, 0.3 mg/kg

● Adenosine was administered in 39 (89%) episodes, with 29 (75%) reverting to NSR

● 12 (30%) received a single dose, 16 (41%) received 2 doses, 9 (24%) received 3 doses, and 2
(4%) received 4 doses
Results
● Mean (SD) dose that reverted SVT to NSR was 0.173 (0.084) mg/kg and mean number of
doses administered was 1.7 (0.8).

● Results suggest that the initial dose recommended by the guidelines for adenosine is
insufficient
Conclusions ● Due to its short half-life and few adverse effects, it may be appropriate to recommend a higher
initial dose of at least 0.2 mg/kg
16
Diaz-Parra, et al. Pediatric Emergency Care 2014.
Adenosine - Supportive Literature
Acute Management of Refractory and Unstable Pediatric Supraventricular Tachycardia

Study Design ● Retrospective: January 2003 to December 2012

Sample Size ● 179 episodes in 134 patients

● Inclusion: 0-18 years of age presenting for acute SVT

Patients ● Exclusion: structural heart disease or previous cardiac surgery

Interventions ● Adenosine (0.05-0.48 mg/kg)

● Vagal maneuvers were recorded in 109 (61%) episodes and were successful in 27 (25%)
episodes
● Conversion to NSR occurred in 72 (56%) episodes after the 1st dose of adenosine and in 27
(50%) episodes after the 2nd dose of adenosine
Results ● Success of vagal maneuvers was greater in infants compared with children >1 yo (P=0.009)
● Conversion to sinus rhythm after a 1st dose of adenosine was lower in infants
compared with children > 1 yo (P<0.001) and lower for episodes with weight < 10 kg
compared with ≥10 kg (P<0.001)

● Infants may have a lower response rate to adenosine - lower conversion after first dose of
adenosine and refractory SVT occurred with greater frequency
Conclusions ● Adenosine 0.2 mg/kg was well tolerated by all infants - data further supports that an initial
dose of 0.2 mg/kg in infants may be appropriate
17
Lewis J, et al. J Pediatr 2017.
Procainamide & Amiodarone

Procainamide Amiodarone

Class III antiarrhythmic: inhibits potassium

Class Ia antiarrhythmic: inhibits sodium
Mechanism of channels, alpha & beta adrenergic
channels - increases electrical stimulation
Action receptors, - decreases AV conduction and
threshold of ventricle
sinus node function

5 mg/kg IV/IO (max dose 300 mg)

Dose 10-15 mg/kg IV/IO (max dose of 500 mg)
● May repeat up to 3 total doses

● 30-60 minutes
● 20-60 minutes
● Dilute loading dose to a maximum
Administration concentration of 20 mg/mL with 5%
● No dilution required - may pull from
premix bag or vial
Dextrose

Place in therapy Place in therapy

● Adenosine-resistant SVT ● Adenosine-resistant SVT
Clinical Pearls Adverse Effects Adverse Effects
● Hypotension ● Hypotension
● Ventricular proarrhythmia ● Bradycardia

18
Topjian AA, et al. Circulation 2020.
Procainamide. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL.
Amiodarone & Procainamide
Supportive Literature
Amiodarone Versus Procainamide for the Acute Treatment of Recurrent Supraventricular Tachycardia in
Pediatric Patients

Study Design ● Retrospective: July 2004 to August 2006

Sample Size ● 40 episodes in 37 patients

● Inclusion: Patients that received amiodarone and/or procainamide to treat SVT

Patients
● Exclusion: Junctional ectopic tachycardia

● Amiodarone (median dose 2.5 mg/kg [1-10 mg/kg]) and/or procainamide (median dose 10
Interventions
mg/kg [3.5-10 mg/kg])

● Amiodarone was initial therapy in 26 episodes and procainamide was initial therapy in 14
episodes
● If partial success is included with full success, procainamide was successful in 10 of 14
Results episodes (71%) compared to amiodarone being successful in 9 of 26 (34%) (P=0.046)
● If partial success is considered failure, procainamide was successful in 7 of 14 (50%)
compared with only 4 of 26 (15%) for amiodarone (P=0.029)
● Adverse events did not differ significantly

● Procainamide may be more effective than amiodarone in the acute treatment of recurrent
Conclusions pediatric SVT without an increase in risk of adverse effects
19
Chang PM, et al. Circ arrhythm electrophysiol 2010.
Key Takeaways

1. Adenosine is the first-line agent when pharmacologic

therapy is appropriate for pediatric SVT
management.

2. Different dosing strategies for adenosine have been

utilized in literature and may be appropriate for
certain populations.

3. Procainamide and amiodarone are safe and effective

alternatives for adenosine-resistant SVT.

4. Current literature suggests that procainamide may

be more effective than amiodarone, but further
studies are warranted.
Back to ED
ED - Long-term Management

Home Medications on Admission:

• Propranolol 20 mg/5 mL 6 mg PO Q8H (1.88 mg/kg/day)

Discharge Medications:
• Propranolol 20 mg/5 mL 8 mg PO Q8H (2.5 mg/kg/day)

Recommended Propranolol Dose for Tachyarrhythmias:

• Initial: 0.5-1 mg/kg/day divided Q6H or Q8H
• Usual dose range: 2-4 mg/kg/day divided Q6H or Q8H

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Propranolol. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL.
Pediatric
Supraventricular
Tachycardia
Emily Letsinger, PharmD
PGY1 Pharmacy Resident