AVNRT medical treatment: Difference between revisions

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==Overview==
==Overview==
There is no treatment for [disease name]; the mainstay of therapy is supportive care.
Place the patient in a supine position to improve cerebral perfusion and reduce the odds of [[syncope]].  Placing the patient in [[Trendelenburg position]] may actually terminate the rhythm.
 
Some people with known AVNRT may be able to stop their attack by using various maneuvers to activate the [[vagus nerve]]. This includes [[carotid sinus massage]] (pressure on the [[carotid sinus]] in the neck), submersion of the face in ice water to trigger the [[diving reflex]], putting the patient in [[Trendelenburg position]] or the [[Valsalva maneuver]] (increasing the pressure in the chest by attempting to exhale against a closed airway). [[Vagal maneuvers]] are contraindicated in the presence of [[hypotension]].
 
In very rare instances, [[cardioversion]] (the electrical restoration of a normal heart rhythm) is needed in the treatment of AVNRT. This would normally only happen if all other treatments have been ineffective, or if the fast heart rate is poorly tolerated (e.g. the development of [[heart failure]] symptoms, [[hypotension]] ([[low blood pressure]]) or [[unconsciousness]]).
 
After being diagnosed with AVNRT, patients can also undergo an electrophysiology (EP) study to confirm the diagnosis. [[Catheter ablation]] of the slow pathway, if successfully carried out, and cures 95% of patients with AVNRT. The risk of complications is quite low.


OR
OR
Line 47: Line 53:


==Medical Therapy==
==Medical Therapy==
*Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
*Adenosine is generally considered first line therapy for AVNRT.  Treatment of AVNRT with adenosine can be complicated by:
*Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
**The development of [[shortness of breath]] due to [[bronchospasm]]
*Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
** In some cases there can be [[asystole]] which is transient given the short [[half life]] of adenosine
*Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
**[[Atrial fibrillation]] may be induced by [[adenosine]] administration
===Disease Name===
**[[Ventricular fibrillation]] is rarely induced by adenosine. When it does occur it is due to block of the [[AV node]] with rapid antegrade conduction of [[atrial fibrillation]] down the bypass tract.  It is for this reason that [[defibrillation]] equipment be available.
**Adenosine should not be used in [[heart transplant]] patients
**[[Dipyridamole]] may potentiate the effect of [[adenosine]]
**[[Theophylline]] may reduce the effectiveness of [[adenosine]] Administration:
**Place a large bore (18 gauge and larger) intravenous line
**The initial dose is 6 mg and this should be followed a saline flush with elevation of the arm to assure that the drug is infused
** If this is not effective, then 12 mg or 18 mg of [[adenosine]] can be admininistered
 
===[[Beta blocker]]s===
A short acting beta-blocker such as [[esmolol]] (half life of 8 minutes) can be used to terminate an episode of AVNRT.  Longer acting beta-blockers such as [[atenolol]], [[metoprolol]], and [[propranolol]] can also be used to reduce the risk of recurrent episodes. [[Atenolol]] may be preferable among patients with [[bronchospasm]] as it selectively blocks [[beta-1 receptors]] with little effect on [[beta- 2 receptors]].
==Second Line Therapy==
Numerous other antiarrhythmic drugs may be effective if the more commonly used medications have not worked; these include [[flecainide]] or [[amiodarone]]. Both adenosine and beta blockers may cause [[bronchoconstriction|tightening of the airways]], and are therefore used with caution in people who are known to have [[asthma]]. Calcium channel blockers should be avoided if there is a [http://www.wikidoc.org/index.php?title=Wide_complex_tacycardia&action=edit&redlink=1 wide complex tacycardia] and the diagnosis of AVNRT is not clearly established in so far as [[calcium channel blockers]] should be avoided in [[ventricular tachycardia]]. If the diagnosis of AVNRT is established, then non-dihydropyridine [[calcium channel blocker]]s (such as [[verapamil]]) may be administered to terminate the rhythm if other agents are not effective.  Verapamil acts longer than adenosine and acts rapidly.  Its administration can be complicated by [[hypotension]], [[bradycardia]] and [[negative inotropic effects]].
==References==
{{Reflist|2}}{{WH}}{{WS}} [[CME Category::Cardiology]]
 
*
 


* '''1 Stage 1 - Name of stage'''
** 1.1 '''Specific Organ system involved 1'''
*** 1.1.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)''' 
**** Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days
**** Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days
**** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
**** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
**** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days
*** 1.1.2 '''Pediatric'''
**** 1.1.2.1 (Specific population e.g. '''children < 8 years of age''')
***** Preferred regimen (1): [[drug name]] 50 mg/kg PO per day q8h (maximum, 500 mg per dose) 
***** Preferred regimen (2): [[drug name]] 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
***** Alternative regimen (1): [[drug name]]10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
****1.1.2.2 (Specific population e.g. '<nowiki/>'''''children < 8 years of age'''''')
***** Preferred regimen (1): [[drug name]] 4 mg/kg/day PO q12h（maximum, 100 mg per dose）
***** Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose) 
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
** 1.2 '''Specific Organ system involved 2'''
*** 1.2.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 500 mg PO q8h
*** 1.2.2  '''Pediatric'''
**** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h (maximum, 500 mg per dose)


* 2 '''Stage 2 - Name of stage'''
*
** 2.1 '''Specific Organ system involved 1 '''
**
**: '''Note (1):'''
*****  
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.1.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.1.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) '<nowiki/>'''''(Contraindications/specific instructions)''''''
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)
** 2.2  '<nowiki/>'''''Other Organ system involved 2''''''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.2.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.2.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)


==References==
==References==

Latest revision as of 19:30, 20 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

Place the patient in a supine position to improve cerebral perfusion and reduce the odds of syncope. Placing the patient in Trendelenburg position may actually terminate the rhythm.

Some people with known AVNRT may be able to stop their attack by using various maneuvers to activate the vagus nerve. This includes carotid sinus massage (pressure on the carotid sinus in the neck), submersion of the face in ice water to trigger the diving reflex, putting the patient in Trendelenburg position or the Valsalva maneuver (increasing the pressure in the chest by attempting to exhale against a closed airway). Vagal maneuvers are contraindicated in the presence of hypotension.

In very rare instances, cardioversion (the electrical restoration of a normal heart rhythm) is needed in the treatment of AVNRT. This would normally only happen if all other treatments have been ineffective, or if the fast heart rate is poorly tolerated (e.g. the development of heart failure symptoms, hypotension (low blood pressure) or unconsciousness).

After being diagnosed with AVNRT, patients can also undergo an electrophysiology (EP) study to confirm the diagnosis. Catheter ablation of the slow pathway, if successfully carried out, and cures 95% of patients with AVNRT. The risk of complications is quite low.

OR

Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].

OR

The majority of cases of [disease name] are self-limited and require only supportive care.

OR

[Disease name] is a medical emergency and requires prompt treatment.

OR

The mainstay of treatment for [disease name] is [therapy].

OR   The optimal therapy for [malignancy name] depends on the stage at diagnosis.

OR

[Therapy] is recommended among all patients who develop [disease name].

OR

Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].

OR

Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].

OR

Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].

OR

Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].

Medical Therapy

  • Adenosine is generally considered first line therapy for AVNRT. Treatment of AVNRT with adenosine can be complicated by:

Beta blockers

A short acting beta-blocker such as esmolol (half life of 8 minutes) can be used to terminate an episode of AVNRT. Longer acting beta-blockers such as atenolol, metoprolol, and propranolol can also be used to reduce the risk of recurrent episodes. Atenolol may be preferable among patients with bronchospasm as it selectively blocks beta-1 receptors with little effect on beta- 2 receptors.

Second Line Therapy

Numerous other antiarrhythmic drugs may be effective if the more commonly used medications have not worked; these include flecainide or amiodarone. Both adenosine and beta blockers may cause tightening of the airways, and are therefore used with caution in people who are known to have asthma. Calcium channel blockers should be avoided if there is a wide complex tacycardia and the diagnosis of AVNRT is not clearly established in so far as calcium channel blockers should be avoided in ventricular tachycardia. If the diagnosis of AVNRT is established, then non-dihydropyridine calcium channel blockers (such as verapamil) may be administered to terminate the rhythm if other agents are not effective. Verapamil acts longer than adenosine and acts rapidly. Its administration can be complicated by hypotension, bradycardia and negative inotropic effects.

References

Template:WHTemplate:WS CME Category::Cardiology


References

Template:WH Template:WS

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