방실결절회귀성빈맥, 재발 발작의 급성 처치, AVNRT, acute management of recurrent episodes

Acute management of recurrent episodes — 재발성 발작의 경우 처치

For the initial management of recurrent AVNRT, we generally work with the patient to develop a patient-directed treatment approach using either ①vagal maneuvers or an ②oral medication ("pill-in-the-pocket" approach). 

대부분의 환자들에게 우리는 pill-in-the-pocket 접근보다는 vagal maneuvers를 제안합니다.

Patients who have experienced prior episodes and who have been educated on the proper performance of vagal maneuvers are frequently able to terminate subsequent episodes by performing vagal maneuvers on their own. If one or more vagal maneuvers successfully terminate the arrhythmia, patients generally do not need to seek urgent medical attention. Conversely, patients should be instructed to consult with their clinician or seek medical attention if the arrhythmia persists in spite of several attempts at patient-directed vagal maneuvers. 

Recurrent AVNRT의 다른 방법은 pill-in-the-pocket입니다.

For selected patients with infrequent, well-tolerated, and long-lasting episodes of AVNRT, a single dose of an antiarrhythmic agent that was previously evaluated under observation can be effective for acute termination of the arrhythmia. This strategy can both reduce the need for emergency department visits and avoid chronic medical therapy or invasive procedures. This approach has been evaluated with the nondihydropyridine calcium channel blockers, beta blockers, digoxin, and the class IC antiarrhythmic drug flecainide. However, based upon the efficacy of alternative, lower-risk therapies, and the efficacy of catheter ablation, flecainide is rarely used in the management of AVNRT. The choice of a particular agent will vary from patient to patient depending on comorbidities and patient preference.

SVT 환자에서 진단적, 치료적 목적을 위해 우리는 전형적으로 Valsalva maneuver로 시작하고 가능하다면 modified Valsalva를 적용합니다. 왜냐하면 Valsalva maneuver가 다른 vagal maneuvers보다 SVT를 종료시키기는데 더 효과적이기 때문입니다.

Valsalva maneuver technique는 다음과 같습니다.

● Most commonly, the patient is placed in a supine or semirecumbent position and instructed to exhale forcefully against a closed glottis after a normal inspiratory effort (ie, at tidal volume). Signs of adequacy include neck vein distension, increased tone in the abdominal wall muscles, and a flushed face. The patient should maintain the strain for 10 to 15 seconds and then release it and resume normal breathing.

● A modified Valsalva maneuver, which involves the standard strain (40 mmHg pressure for 15 seconds in the semirecumbent position) followed by supine repositioning with 15 seconds of passive leg raise at a 45 degree angle, has been shown to be more successful in restoring sinus rhythm for patients with SVT. In the largest randomized trial of vagal maneuvers for the treatment of SVT, patients performing the modified Valsalva maneuver with supine repositioning and passive leg raise were significantly more likely to have restoration of sinus rhythm at one minute (43 versus 17 percent in the standard Valsalva group; adjusted odds ratio 3.7; 95% CI 2.3-5.8). When feasible, the modified Valsalva maneuver should be performed given the greater likelihood of successful restoration of sinus rhythm. 

Modified Valsalva maneuver 방법은 다음과 같습니다.

https://youtu.be/8DIRiOA_OsA