NO DRUG THERAPY IN PRIMARY CARE (REFERRAL & ADVICE)
Paroxysmal tachycardia presents with sudden episodes of palpitations. Primary care management requires immediate 12-lead ECG recording during symptoms to identify the rhythm mechanism (e.g. SVT vs VT vs WPW). If the patient is hemodynamically stable, attempt vagal maneuvers (e.g. Valsalva maneuver); if unstable (hypotension, altered mental status, chest pain) or if WPW is present, arrange immediate emergency transfer for electrical cardioversion or specialized antiarrhythmic therapy. - Refer, with advice
Children follow the same pathway: recognise and refer. No primary-care medicine is implied.
No dose - referral pathway, no medicine given in primary care
Paroxysmal tachycardia presents with sudden episodes of palpitations. Primary care management requires immediate 12-lead ECG recording during symptoms to identify the rhythm mechanism (e.g. SVT vs VT vs WPW). If the patient is hemodynamically stable, attempt vagal maneuvers (e.g. Valsalva maneuver); if unstable (hypotension, altered mental status, chest pain) or if WPW is present, arrange immediate emergency transfer for electrical cardioversion or specialized antiarrhythmic therapy.
- RED FLAG - Ventricular fibrillation or rapid ventricular response in pre-excited atrial fibrillation (Wolff-Parkinson-White): assess urgently and refer.
- Syncope or near-syncope, chest pain during episodes, haemodynamic instability, pre-excitation pattern on ECG.
- No medicine is prescribed for this in primary care - this entry is for recognition and referral. Anything given is decided by the service it is referred to.
- RED FLAG - Syncope, rapid atrial fibrillation, or LV dysfunction in patients with SVT or preexcitation indicate severe disease requiring specialist referral for catheter ablation.
- RED FLAG - Recurrent symptomatic SVT with unclear arrhythmia mechanism or syncope with inconclusive noninvasive testing warrants electrophysiology study referral.
- RED FLAG - Do not prescribe AV-nodal blocking drugs to a patient with manifest pre-excitation and symptomatic supraventricular tachycardia; they speed conduction of atrial fibrillation down the accessory pathway and raise the risk of ventricular fibrillation.
- Carotid sinus massage is contraindicated when a carotid bruit is present, and vagal manoeuvres overall terminate fewer than 30% of episodes.
- Frequent episodes, especially atrial tachycardia, can cause new-onset heart failure through tachycardia-induced cardiomyopathy.
- RED FLAG - In older patients and those with coronary disease a very fast rate can provoke myocardial ischaemia, and incessant episodes can rarely degenerate into life-threatening ventricular arrhythmias.
- Arrange a transthoracic echocardiogram to assess left ventricular systolic function and exclude structural heart disease.
- Look for and correct reversible triggers: physical exertion, stress, caffeine, nicotine, hyperthyroidism, myocardial ischaemia, infection, hypoxia and hypovolaemia.
- In a patient taking digoxin, consider digoxin toxicity as a cause of the tachycardia.
- RED FLAG - Explain the risk of sudden cardiac death to patients with Wolff-Parkinson-White syndrome and recommend catheter ablation as the primary treatment.