Understanding SVT and Atrial Fibrillation

Ramin Davoudi MD

Medical Director

Cardiac Arrhythmia Service

Disclosures

• Speaker’s Bureau: Boston Scientific, Biotronik, Boerhinger-Ingelheim

• Research: Biotronik, Boston Scientific, St Jude Medical

• Corporate Investments: None

Objectives

• Understand pathophysiology of SVT

• Identify different SVT’s

• Understand treatment options of a fib

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Mechanisms of SVT

• Automaticity

• Triggered Activity

• Re-entry

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Types of SVT

• AV nodal reentrant tachycardia (70%)

• AV reentrant tachycardia (20%)

• Atrial tachycardia (9%)

• Junctional tachycardia (1%)

• Atrial Flutter

• Atrial Fibrillation

SVT: Long RP vs Short RP

AVNRT

AVNRT

AVRT

Atrial Flutter

• Typical

• Counterclockwise/clockwise

• Atypical

Atrial Flutter

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Atrial Fibrillation

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Fire and ICE

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Kuck et al. NEJM 2016

22Kuck et al. NEJM 2016

23 Roy et al NEJM 2000

24 Pappone et al. JACC 2003

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Wyse et al. NEJM 2002

AFFIRM STUDY

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Treatment

• Beta blockers

• Calcium Channel blockers

• Antiarrhythmic Medications

• Atrial fibrillation – Amiodarone, Sotalol, Dofetilide, Flecainide, Propafenone

• AVRT – Flecainide, Propafenone, Amiodarone

Amiodarone

• Most potent

• CHF safe

• Torsades

• Liver metabolism

• Extracardiac

• Skin

• Pulmonary

• Thyroid

• Lung

• Nervous system

• GI

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Sotalol

• Kidney

• Little Drug - Drug interaction

• Not very potent

• Torsades

• ? CHF safe

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Tikosyn

• Kidney

• Drug interactions - Verapamil, Bactrim, HCTZ

• Slightly more potent than sotalol

• Torsades

• CHF safe

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Flecainide/Propafenone

• Not CHF safe

• Liver/kidney

• Drug interactions

• Not many side effects (metallic taste, tremor, headache)

• Rare Torsades - mostly conduction issues

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Conclusions

• SVT mechanisms are few

• Drugs are moderately effective

• Treating SVT is becoming increasingly catheter based

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QUESTIONS?

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