Paeds · cardiology
Supraventricular tachycardia
Also known as SVT · Paroxysmal supraventricular tachycardia · AV re-entry tachycardia · AV nodal re-entry tachycardia · Wolff-Parkinson-White syndrome
Fellowship guide to supraventricular tachycardia in children: the mechanisms (AVRT in infants, AVNRT in adolescents), the clinical presentations from irritable pale infant to palpitating teenager, the ECG hallmarks of a fast regular narrow complex, the stepwise acute termination with vagal manoeuvres and adenosine, long-term pharmacological control, catheter ablation, the special case of Wolff-Parkinson-White syndrome and sudden death risk, and the AHA/ACC/HRS, ESC and PACES/EHRA guideline positions.
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- An infant with a heart rate above 220 per minute who is pale, irritable and feeding poorly is in SVT until proven otherwise — terminate it with vagal manoeuvres and adenosine; do not observe a fast heart rate
- A haemodynamically unstable child in SVT needs immediate synchronised DC cardioversion at 0.5 to 1 joule per kilogramme — do not delay for intravenous access or an adenosine trial
- A child with a Wolff-Parkinson-White pattern on the resting ECG has a small but real risk of sudden cardiac death from rapid conduction down the accessory pathway during atrial fibrillation — risk stratify with exercise testing or electrophysiological study
- Permanent junctional reciprocating tachycardia (PJRT) is an incessant, drug-resistant SVT that can cause a tachycardiomyopathy — suspect it when the ECG shows a long RP tachycardia with negative P waves in the inferior leads
- Adenosine must be given as a rapid bolus through a large-bore cannula closest to the heart, followed immediately by a saline flush — a slow push will be metabolised before it reaches the AV node and will appear to fail
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Care settings
Clinical exam formats
Board mappings
- Cardiology
- Arrhythmia
- Supraventricular tachycardia
- Paediatric Cardiology — cardiac arrhythmia
- General Paediatrics learning goal — recognise and terminate SVT
- Wolff-Parkinson-White syndrome and sudden death risk
- Clinical Applications
- Arrhythmia management
- Long Cases
- Short Cases
- Communication scenarios
- Cardiology: recognises and manages supraventricular tachycardia
- Acute management of a tachyarrhythmic infant
- Lifelong follow-up of Wolff-Parkinson-White syndrome
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Cardiac arrhythmia
- Clinical
- History
- Communication
- Cardiovascular examination
- General Pediatrics Content Outline — Domain 9: Cardiology
- Subspecialty: Pediatric Cardiology — arrhythmia
- Patient Care 1: History and Physical Examination
- Patient Care 4: Clinical Reasoning
- Medical Knowledge 1: Clinical Knowledge of cardiac arrhythmia
- Systems-Based Practice 1: multidisciplinary arrhythmia care
- Medical Expert
- Collaborator
- Pediatrics: Core EPA — recognise and terminate SVT
Overview & Definition
Picture the four-month-old brought to the emergency department pale and floppy after a feed, whose nurse says the heart rate monitor reads 250 and will not come down. The mother says he has been fussier at feeds for a day. You attach leads and see a regular narrow-complex tachycardia at 260 per minute with no visible P waves. That child carries the whole story of paediatric SVT — the commonest significant arrhythmia of childhood, and one where prompt recognition and a single drug can reverse heart failure within seconds. [3]
Supraventricular tachycardia is a rapid, regular tachycardia originating from a circuit or focus above the His bundle. The heart rate is typically 220 to 280 per minute in infants and 180 to 240 per minute in older children, which distinguishes SVT from sinus tachycardia where the rate rarely exceeds 220 in an infant and varies with stimulation. The mechanism is usually a reentrant circuit — a self-sustaining electrical loop — though a minority are driven by an automatic ectopic focus. [1] [2]
The clinical importance of SVT rests on three facts. It is eminently treatable — most episodes terminate with vagal manoeuvres or adenosine, and catheter ablation is curative. Infants often present non-specifically with poor feeding, irritability and pallor, so the diagnosis is missed unless a heart rate is measured and an ECG obtained. And Wolff-Parkinson-White syndrome, the most important substrate for SVT in children, carries a small but real risk of sudden cardiac death that demands assessment and sometimes ablation. [4] [9]
References15ShowHide
- [1]Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia. J Am Coll Cardiol, 2016.PMID 26409259
- [2]Brugada J, Katritsis DG, Arbelo E, et al. 2019 ESC Guidelines for the management of patients with supraventricular tachycardia. Eur Heart J, 2020.PMID 31504425
- [3]Brugada J, Blom N, Sarquella-Brugada G, et al. Pharmacological and non-pharmacological therapy for arrhythmias in the pediatric population: EHRA and AEPC-Arrhythmia Working Group joint consensus statement. Europace, 2013.PMID 23851511
- [4]Cohen MI, Triedman JK, Cannon BC, et al. PACES/HRS expert consensus statement on the management of the asymptomatic young patient with a Wolff-Parkinson-White (WPW, ventricular preexcitation) electrocardiographic pattern. Heart Rhythm, 2012.PMID 22579340
- [5]Paul T, Krause U, Sanatani S, et al. Advancing the science of management of arrhythmic disease in children and adult congenital heart disease patients within the last 25 years. Europace, 2023.PMID 37622573
- [6]Wei N, Lamba A, Franciosi S, et al. Medical Management of Infants With Supraventricular Tachycardia: Results From a Registry and Review of the Literature. CJC Pediatr Congenit Heart Dis, 2022.PMID 37969556
- [7]Kang KT, Etheridge SP, Kantoch MJ, et al. Current management of focal atrial tachycardia in children: a multicenter experience. Circ Arrhythm Electrophysiol, 2014.PMID 25015944
- [8]Appelboam A, Reuben A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet, 2015.PMID 26314489
- [9]Al-Khatib SM, Arshad A, Balk EM, et al. Risk Stratification for Arrhythmic Events in Patients With Asymptomatic Pre-Excitation: A Systematic Review for the 2015 ACC/AHA/HRS SVT Guideline. J Am Coll Cardiol, 2016.PMID 26409260
- [10]Kang KT, Potts JE, Radbill AE, et al. Permanent junctional reciprocating tachycardia in children: a multicenter experience. Heart Rhythm, 2014.PMID 24769425
- [11]Obeyesekere MN, Klein GJ Preventing Sudden Death in Asymptomatic Wolf-Parkinson-White Patients. JACC Clin Electrophysiol, 2018.PMID 30067482
- [12]Losek JD, Endom E, Dietrich A, Stewart G, Zempsky W, Smith K Adenosine and pediatric supraventricular tachycardia in the emergency department: multicenter study and review. Ann Emerg Med, 1999.PMID 9922414
- [13]Van Hare GF, Javitz H, Carmelli D, et al. Prospective assessment after pediatric cardiac ablation: demographics, medical profiles, and initial outcomes. J Cardiovasc Electrophysiol, 2004.PMID 15250858
- [14]Campbell RM, Strieper MJ, Frias PA, Collins KK, Van Hare GF, Dubin AM Survey of current practice of pediatric electrophysiologists for asymptomatic Wolff-Parkinson-White syndrome. Pediatrics, 2003.PMID 12612279
- [15]Van Hare GF, Carmelli D, Smith WM, et al. Prospective assessment after pediatric cardiac ablation: design and implementation of the multicenter study. Pacing Clin Electrophysiol, 2002.PMID 11990663