Treatment of supraventricular tachycardia in infants: Analysis of a large multicenter database

https://doi.org/10.1016/j.earlhumdev.2015.04.001Get rights and content

Highlights

  • In-hospital recurrence of supraventricular tachycardia in infants is common.

  • Antiarrhythmic therapy practices vary widely, especially for drugs used as secondary prevention.

  • Adverse events are common in infants exposed to antiarrhythmic drugs.

Abstract

Objective

Supraventricular tachycardia (SVT) is the most common arrhythmia in infants. Infants are typically treated with antiarrhythmic medications, but there is a lack of evidence guiding management, thus exposing infants to risks of both inadequate therapy and medication adverse events. We used data from a large clinical database to better understand current practices in SVT management, safety of commonly used medications, and outcomes of hospitalized infants treated for SVT.

Methods

This retrospective data analysis included all infants discharged from Pediatrix Medical Group neonatal intensive care units between 1998 and 2012 with a diagnosis of SVT who were treated with antiarrhythmic medications. We categorized infants by the presence of congenital heart disease other than patent ductus arteriosus. Medications were categorized as abortive, acute, or secondary prevention therapies. We used descriptive statistics to describe medication use, adverse events, and outcomes including SVT recurrence and mortality.

Results

A total of 2848 infants with SVT were identified, of whom 367 (13%) had congenital heart disease. Overall, SVT in-hospital recurrence was high (13%), and almost one fifth of our cohort (18%) experienced an adverse event. Mortality was 2% in the overall cohort and 6% in the congenital heart disease group (p < 0.001). Adenosine was the most commonly used abortive therapy, but there was significant practice variation in therapies used for acute treatment and secondary prevention of SVT.

Conclusion and practice implication

Significant variation in SVT treatment and suboptimal outcomes warrant future clinical trials to determine best practices in treating SVT in infants.

Introduction

Supraventricular tachycardia (SVT) is the most common arrhythmia in infants, with an estimated incidence of 1/250 to 1/1000 among all infants and 1/10 among infants with congenital heart disease (CHD) [1], [2], [3], [4], [5], [6]. Medications used to treat SVT typically fall into one of three categories: 1) abortive therapies; 2) acute management therapies used to achieve rate control or improve the likelihood of arrhythmia abortion; and 3) secondary prevention or “prophylactic” therapies used to prevent SVT recurrence [7], [8]. Across this therapeutic spectrum, over a dozen different therapies are used to treat SVT.

Although a broad armamentarium of therapies is available, there is limited evidence to guide management. Current practices are based on survey data, small clinical trials, and retrospective studies involving few (< 300) infants [7], [9], [10], [11], [12], [13], [14], [15], [16]. There are no Food and Drug Administration (FDA)-labeled medications for SVT in pediatric populations, and the safety profile of commonly used medications has not been well described in infants. This is of particular importance in infants with CHD who are at high risk of adverse events and poor outcomes.

To better understand current practices in SVT management, safety of commonly used medications, and outcomes of hospitalized infants treated for SVT, we conducted a retrospective cohort study using a large database. Results of our study are useful for guiding management and identifying priorities for future clinical trials required for FDA medication labeling.

Section snippets

Database and study cohort

We performed a retrospective cohort study using data generated from electronic medical records (EMR) of infants cared for by clinicians in one of 348 neonatal intensive care units (NICUs) managed by the Pediatrix Medical Group from 1998 to 2012. The data are de-identified and stored in the Pediatrix Clinical Data Warehouse [17]. We included all infants discharged with a diagnosis of SVT who received SVT therapy during their first 120 days of life. SVT diagnosis was based on the clinical

Patient demographics

Of the 887,910 infants present in the database, 2848 (0.3%) infants met our inclusion criteria and were included in this analysis. The median (interquartile range) gestational age and birth weight of the included infants was 37 weeks (34, 38) and 2950 g (2210, 3520). Median postnatal age at diagnosis was 2 days (0, 8), and 1869/2848 (66%) were diagnosed with SVT in the first week of life. Underlying arrhythmia diagnoses included unspecified SVT (2200/2848, 77%), atrial flutter (448/2848, 16%), and

Discussion

This is the largest study to date evaluating treatment practices and in-hospital outcomes of infants with SVT. Overall, SVT in-hospital recurrence was high (13%), and almost one fifth of our cohort experienced an AE while receiving secondary prevention therapy. In addition, we found significant practice variation in medications used to treat SVT. Taken together, these findings suggest that further studies are needed to establish best practices in treatment of SVT in infants to improve outcomes

Conflict of interest

The authors have no potential conflict of interest.

Acknowledgments

Funding disclosure

P.Y.C. and R.H.C. do not have any financial disclosures. National Institutes of Health (NIH) and the National Center for Advancing Translational Sciences of the NIH (UL1TR001117), the National Institute of Child Health and Human Development (HHSN2752010000031 and 1R01-HD081044-01) and the Food and Drug Administration (1R18-FD005292-01); he also receives research support from Cempra Pharmaceuticals (subaward to HHS0100201300009C) and industry for neonatal and pediatric drug

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