Table 6

Acute Drug Therapy for SVT, Intravenous Administration

DrugInitial DoseSubsequent or Maintenance DosePotential Adverse EffectsPrecautions (Exclude or Use With Caution) and Interactions
Nucleoside
Adenosine6-mg rapid IV bolus (injected into IV as proximal or as close to the heart as possible), administered over 1–2 s, followed by rapid saline flushIf no result within 1–2 min, 12-mg rapid IV bolus; can repeat 12-mg dose 1 time. The safe use of 18-mg bolus doses has been reported (117).Transient AV block, flushing, chest pain, hypotension, or dyspnea, AF can be initiated or cause decompensation in the presence of pre-excitation, PVCs/ventricular tachycardia, bronchospasm (rare), or coronary steal. Minor side effects are usually transient because of adenosine’s very short half-life.
  • AV block greater than first degree or SA node dysfunction (in absence of pacemaker)

  • Reactive airway disease

  • Concomitant use of verapamil or digoxin

  • WPW

Beta blockers
Esmolol500-mcg/kg IV bolus over 1 minInfusion at 50–300 mcg/kg/min, with repeat boluses between each dosing increaseHypotension, worsening HF, bronchospasm, bradycardia
  • AV block greater than first degree or SA node dysfunction (in absence of pacemaker)

  • Decompensated systolic HF

  • Hypotension

  • Cardiogenic shock

  • Reactive airway disease

  • Renal dysfunction

  • Drugs with SA and/or AV nodal–blocking properties

Metoprolol tartrate2.5–5.0-mg IV bolus over 2 minCan repeat 2.5- to 5.0-mg IV bolus in 10 min, up to 3 dosesHypotension, worsening HF, bronchospasm, bradycardia
  • AV block greater than first degree or SA node dysfunction (in absence of pacemaker)

  • Decompensated systolic HF

  • Hypotension

  • Reactive airway disease

  • Drugs with SA and/or AV nodal–blocking properties

Propranolol1 mg IV over 1 minCan repeat 1 mg IV at 2-min intervals, up to 3 dosesHypotension, worsening HF, bronchospasm, bradycardia
  • AV block greater than first degree or SA node dysfunction (in absence of pacemaker)

  • Cardiogenic shock

  • Reactive airway disease

  • Decompensated HF

  • Hypotension

  • Hepatic or renal dysfunction

  • Drugs with SA and/or AV nodal–blocking properties

Nondihydropyridine calcium channel antagonists
Diltiazem0.25-mg/kg IV bolus over 2 minInfusion at 5–10 mg/h, up to 15 mg/hHypotension, worsening HF in patients with pre-existing ventricular dysfunction, bradycardia, abnormal liver function studies, acute hepatic injury (rare)
  • AV block greater than first degree or SA node dysfunction (in absence of pacemaker)

  • WPW with AF/atrial flutter

  • Hypotension

  • Decompensated systolic HF/LV dysfunction

  • Drugs with SA and/or AV nodal–blocking properties

  • Hepatic or renal dysfunction

  • Diltiazem is a substrate of CYP3A4 (major) and a moderate CYP3A4 inhibitor

  • Apixaban, itraconazole, bosutinib, ceritinib, cilostazol, cyclosporine, everolimus, ibrutinib, idelalisib, ivabradine, lomitapide, olaparib, posaconazole, ranolazine, rifampin, simeprevir, voriconazole

Verapamil5–10-mg (0.075–0.15-mg/kg) IV bolus over 2 minIf no response, can give an additional 10 mg (0.15 mg/kg) 30 min after first dose; then infusion at 0.005 mg/kg/minHypotension, worsening HF in patients with pre-existing ventricular dysfunction, pulmonary edema in patients with hypertrophic cardiomyopathy, bradycardia
  • AV block greater than first degree or SA node dysfunction (in absence of pacemaker)

  • Decompensated systolic HF/LV dysfunction

  • Drugs with SA and/or AV nodal–blocking properties

  • Hypotension

  • Cardiogenic shock

  • WPW with AF/atrial flutter

  • Hepatic or renal dysfunction

  • Verapamil is a moderate CYP3A4 inhibitor and also inhibits P-glycoprotein

  • Contraindicated with dofetilide

  • Itraconazole, bosutinib, ceritinib, cilostazol, colchicine, cyclosporine, everolimus, dabigatran, edoxaban, flecainide, ibrutinib, ivabradine, olaparib, posaconazole, ranolazine, rivaroxaban, rifampin, silodosin, simeprevir, rivaroxaban, rifampin, simvastatin, topotecan, trabectedin, vincristine, voriconazole, grapefruit juice

Cardiac glycosides
Digoxin0.25–0.5-mg IV bolusCan repeat 0.25-mg IV bolus, up to maximum dose of 1.0 mg over 24 h (i.e., maximum loading dose 8–12 mcg/kg), given at 6–8-h intervals; maintenance dose based on patient’s age, lean body weight, renal function, and concomitant drugs (IV 2.4–3.6 mcg/kg/d)Anorexia, nausea, vomiting, visual changes and cardiac arrhythmias if digoxin toxicity (associated with levels >2 ng/mL, although symptoms may also occur at lower levels)
  • Renal dysfunction

  • WPW with AF/atrial flutter

  • AV block greater than first degree or SA node dysfunction (in absence of pacemaker)

  • Drugs with AV nodal-blocking properties

  • Digoxin is a P-glycoprotein substrate

  • Dronedarone (reduce dose by at least 50%), amiodarone (reduce dose by 30%–50%)

  • Verapamil, clarithromycin, cyclosporine, erythromycin, flecainide, itraconazole, posaconazole, propafenone, voriconazole: Monitor digoxin levels

  • A large retrospective study suggested an increased risk in mortality in patients who were treated with digoxin for newly diagnosed AF or atrial flutter; although the data were collected from a population that was different from SVT patients, digoxin should be used with caution (118).

Class III antiarrhythmic agents
Amiodarone150 mg IV over 10 minInfusion at 1 mg/min (360 mg) over next 6 h; then 0.5 mg/min (540 mg) over remaining 18 hHypotension, bradycardia, phlebitis, QT prolongation, torsades de pointes (rare), increased INR
  • Sinus or AV conduction disease (in absence of pacemaker)

  • Inflammatory lung disease (acute)

  • Hepatic dysfunction

  • Drugs with SA and/or AV nodal–blocking properties

  • Amiodarone is a substrate of and inhibits p-glycoprotein and CYP2C9 (moderate), CYP2D6 (moderate), and CYP3A4 (weak); amiodarone is a substrate for CYP3A4 (major) and CYP2C8 (major);amiodarone is an inhibitor of OCT2

  • Reduce warfarin dose by 50% and reduce digoxin dose by 30%–50%

  • Agalsidase alfa, agalsidase beta, azithromycin, bosutinib, ceritinib, colchicine, dabigatran, edoxaban, flecainide, ivabradine, ledipasvir/sofosbuvir, lopinavir, lopinavir/ritonavir, lovastatin, nelfinavir, pazopanib, propafenone, simvastatin, ritonavir, rivaroxaban, saquinavir, sofosbuvir, topotecan, vincristine, grapefruit juice

IbutilideContraindicated when QTc >440 ms; 1 mg over 10 min (if ≥60 kg); if <60 kg, then 0.01 mg/kgCan repeat 1 mg once, if the arrhythmia does not terminate within 10 min§QT prolongation, torsades de pointes, AV block
  • Prolonged QT interval

  • History of torsades de pointes

  • Avoid other QT interval–prolonging drugs

  • Concurrent administration of high-dose magnesium has been associated with enhanced efficacy and safety (119,120)

Note: For this reference table, drugs are presented in alphabetical order within the drug classes, not by COR and LOE.

AF indicates atrial fibrillation; AV, atrioventricular; BID, twice daily; COR, Class of Recommendation; HF, heart failure; INR, international normalized ratio; IV, intravenous; LOE, Level of Evidence; LV, left ventricular; PVC, premature ventricular contraction; QTc, corrected QT interval; SA, sinoatrial; SVT, supraventricular tachycardia; and WPW, Wolff-Parkinson-White.

  • When 1 drug is used in combination with other drugs, appropriate dosing adjustments should be made with consideration of at least additive effects during dosage titration. All potential drug–drug interactions are not included in this list. For a more detailed list of drug–drug interactions, clinicians should consult additional resources.

  • If hypotension is a consideration, a slow infusion of diltiazem (2.5 mg/min) or verapamil (1 mg/min) for up to 20 minutes may lessen the potential for hypotension (92).

  • QTc calculation used the Bazett’s Formula in most clinical studies. Patients should be observed with continuous ECG monitoring for at least 4 h after infusion or until QTc has returned to baseline.

  • § The infusion should be stopped as soon as the arrhythmia is terminated or in the event of sustained or nonsustained ventricular tachycardia or marked prolongation of QT or corrected QT interval.