Paroxysmal Supraventricular Tachycardia (PSVT)

  • Medical Author:
    Benjamin Wedro, MD, FACEP, FAAEM

    Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.

  • Medical Editor: Daniel Lee Kulick, MD, FACC, FSCAI
    Daniel Lee Kulick, MD, FACC, FSCAI

    Daniel Lee Kulick, MD, FACC, FSCAI

    Dr. Kulick received his undergraduate and medical degrees from the University of Southern California, School of Medicine. He performed his residency in internal medicine at the Harbor-University of California Los Angeles Medical Center and a fellowship in the section of cardiology at the Los Angeles County-University of Southern California Medical Center. He is board certified in Internal Medicine and Cardiology.

  • Medical Editor: Melissa Conrad Stöppler, MD
    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD

    Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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What is paroxysmal supraventricular tachycardia (PSVT)?

The heart is a two-stage electrical pump. A coordinated electrical signal is required for the heart muscle cells to contract in a coordinated way and generate a heartbeat. Normally, an electrical signal is generated in special pacemaker cells found in the sinoatrial (SA) node located in the right atrium or upper chamber of the heart. This impulse spreads to the whole atrial muscle causing it to contract and push blood into the ventricle or the lower chamber of the heart. The electrical signal continues to a junction box between the atrium and ventricle (the AV node), where there is a slight delay that allows the ventricle to fill before it contracts and pumps blood to the body. The signal continues throughout the ventricles and causes them to beat and push blood to the body.

What causes paroxysmal supraventricular tachycardia (PSVT)?

In paroxysmal supraventricular tachycardia (PSVT), abnormal conduction of that electricity causes the atrium, and secondarily the ventricles, to beat very rapidly. It is referred to as paroxysmal, because the rapid rate can occur sporadically and without warning and may also stop on its own. The rapid heartbeat may last a few seconds or many hours. Often the PSVT resolves before the patient reaches a health care professional.

In many patients with PSVT, there is a “wiring” problem in the AV node and instead of having just one pathway for electricity to travel to the ventricle, there are two. This allows electricity to circle back and cause the atrium to beat more quickly than it should normally. PSVT is one of many electrical abnormalities that cause the atrium to beat too quickly. These abnormalities were once lumped together and called paroxysmal atrial tachycardia or PAT but, as more has been learned about the electrical wiring of the heart, terminology has been updated to better reflect the specific abnormal rhythm. Some examples include atrial tachycardia, multifocal atrial tachycardia, atrial fibrillation, atrial flutter, and Wolff-Parkinson-White (WPW) syndrome. As well, there are numerous abnormalities in the AV node that cause rapid heartbeats and palpitations. PSVT and other electrical abnormalities located in the atrium or AV node should not be confused with ventricular tachycardia, which arises from the ventricle and is potentially life-threatening.

Picture of the interior of the heart and chambers of the heart.
Picture of the interior of the heart and chambers of the heart.

PSVT Treatment: Ablation

Ablation is used to treat abnormal heart rhythms, or arrhythmias. The type of arrhythmia and the presence of other heart disease will determine whether ablation can be performed surgically or non-surgically.

Non-surgical ablation, used for many types of arrhythmias, is performed in a special lab called the electrophysiology (EP) laboratory.

  • During this non-surgical procedure a catheter is inserted into a specific area of the heart.
  • A special machine directs energy through the catheter to small areas of the heart muscle that causes the abnormal heart rhythm.
  • This energy "disconnects" the pathway of the abnormal rhythm. It can also be used to disconnect the electrical pathway between the upper chambers (atria) and the lower chambers (ventricles) of the heart.

What are the symptoms of paroxysmal supraventricular tachycardia (PSVT)?

One of the most common symptom of PSVT is heart palpitations, often described as a "rapid heartbeat." There can also be a fullness in the throat that is associated with the rapid heartbeat.

Other symptoms include the following:

The symptoms of PSVT usually occur while the heart is beating quickly, but the fatigue can persist after the heartbeat returns to normal. By its nature, PSVT is intermittent and its onset cannot be predicted. As well, once the heart starts to beat quickly, there is no way of predicting if and when it will return to normal rhythm on its own. Some patients are unaware that their heart is beating quickly and PSVT is found only when the patient presents for care and is found to have a rapid heartbeat.

How is paroxysmal supraventricular tachycardia (PSVT) diagnosed?

The diagnosis of PSVT is based upon interpretation of the heart rate monitor and electrocardiogram.

Sometimes the diagnosis is difficult because the rapid heart rate resolves before the patient presents for medical care. In these cases, where there is a recurrent pattern of palpitations, the healthcare professional may suggest monitoring the patient's heart rate and rhythm as an outpatient. A Holter monitor is a small device that can be worn for 24 or 48 hours that records every heartbeat and may give a clue as to the underlying cause of the palpitations. A 30-day event monitor may also be considered, which gives a longer window to detect the rhythm. Again, a small monitor is worn, but with this device the patient triggers the recording when the palpitations begin. In some cases, specialized electrophysiology tests may be necessary to monitor the heart and try to reproduce abnormal rhythms.

For infrequent events, an implantable device (LINQ) can be placed just under the skin, and can scan for a month looking for rare rhythm changes.

What is the treatment for paroxysmal supraventricular tachycardia (PSVT)?

There is a stepwise approach to treating the rapid heartbeat of PSVT.

Vasovagal maneuvers stimulate the vagus nerve and can slow the heart rate. Some options include holding one's breath and bearing down as if to have a bowel movement or splashing cold water on the face. A care professional might cautiously massage the carotid artery in the neck, but in older patients, there is a risk of stroke and this procedure is usually reserved for younger patients.

Depending upon the heart rhythm, medications can be injected intravenously to reset the AV node or to decrease heart muscle excitability. Adenosine is a short-acting medication that is commonly used as a first-line drug to treat PSVT. Other treatment options for other atrial tachycardias include calcium channel blockers, beta blockers, digoxin, and amiodarone.

If the PSVT does not convert with intravenous medication or if the patient has low blood pressure or complains of chest pain or shortness of breath, cardioversion may be required. This means that an electrical shock is given that resets the heart's electrical system to beat with a regular rate and rhythm.

How can paroxysmal supraventricular tachycardia (PSVT) be prevented?

PSVT can result because of underlying medical conditions or because of foods and medications that are ingested. Caffeine, alcohol, and over-the-counter (OTC) cold medications that contain pseudoephedrine can stimulate and irritate the heart's electrical conduction system and precipitate an episode of PSVT. Decreasing or avoiding use of these chemicals completely may prevent PSVT. Electrolytes abnormalities can cause heart electrical irritability. Abnormal thyroid levels can also precipitate abnormal heart rhythms.

Medications can be used to minimize the recurrence of PSVT, including calcium channel blockers, beta blockers, or other antiarrhythmic medications.

If PSVT continues to recur, an electrophysiologic study (EPS) can be done by a cardiologist and the electrical system of the heart can be mapped. If abnormal tracts or short circuits are found, they can be ablated or destroyed with high frequency radio waves and hopefully, prevent future episodes of PSVT. This is often a highly effective modality for patients with recurrent episodes who don't wish to have to take long-term medication.

Medically reviewed by Robert J. Bryg, MD; Board Certified Internal Medicine with subspecialty in Cardiovascular Disease

REFERENCE:

Tintinalli, Judith E., et al. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th edition. McGraw-Hill Education, 2011.

Last Editorial Review: 3/14/2016

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Reviewed on 3/14/2016
References
Medically reviewed by Robert J. Bryg, MD; Board Certified Internal Medicine with subspecialty in Cardiovascular Disease

REFERENCE:

Tintinalli, Judith E., et al. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th edition. McGraw-Hill Education, 2011.

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