Blomström-Lundqvist
ET AL., MANAGEMENT OF PATIENTS WITH Supraventricular
Arrhythmias
J
Am Coll Cardiol 2003;42:1493–531
ACC/AHA/ESC
Guidelines for the Management of Patients With Supraventricular
Arrhythmias
A
Report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines and the European Society of Cardiology
Committee for Practice Guidelines (Writing Committee to Develop
Guidelines for the Management of Patients With Supraventricular
Arrhythmias)
II. PUBLIC HEALTH CONSIDERATIONS
AND
EPIDEMIOLOGY
Supraventricular arrhythmias are relatively common,
often repetitive, occasionally persistent, and rarely life threatening
(2). The precipitants of supraventricular
arrhythmias vary with age, gender, and associated comorbidity (3).
While supraventricular arrhythmias are a frequent cause of emergency
room (4,5) and primary care physician
(6) visits, they are infrequently
the primary reason for hospital admission (3,7).
Failure
to discriminate among AF, atrial flutter, and other supraventricular
arrhythmias has complicated the precise definition of this arrhythmia
in the general population (8). The
estimated prevalence of ischemic heart disease in the adult U.S.
population is approximately tenfold greater than that of supraventricular
arrhythmias (78 per 1000 vs. 6 to 8 per 1000, respectively) (9).
The estimated prevalence of paroxysmal supraventricular tachycardia
(PSVT) in a 3.5% sample of medical records in the Marshfield (Wisconsin,
U.S.A.) Epidemiologic Study Area (MESA) was 2.25 per 1000 (10).
The incidence of PSVT in this survey was 35 per 100 000 person-years
(10).
Occurrence
rates have been determined for various sub- types of supraventricular
arrhythmia after acute myocardial infarction (11)
or coronary artery bypass graft surgery (12)
and in congestive heart failure (CHF) patients (13).
The incidence rate of supraventricular arrhythmias among patients
with CHF is 11.1% (13); paroxysms
are more common in older patients, males, and those with longstanding
CHF and radiographic evidence of cardiomegaly.
Age
exerts an influence on the occurrence of SVT. The mean age at the
time of PSVT onset in the MESA cohort was 57 years (ranging from
infancy to more than 90 years old) (3).
Among emergency room patients older than 16 years treated with intravenous
(IV) adenosine for supraventricular arrhythmias diagnosed by surface
electrocardiogram (ECG) criteria, 9% had atrial flutter and 87%
had SVT (4); 70% of these patients
(age 51 plus or minus 19 years) reported a history of cardiovascular
disease. In the MESA population (10),
compared to those with other cardiovascular disease, “lone”
(no cardiac structural disease) PSVT patients without associated
structural heart disease were younger (mean age equals 37 vs. 69
years), had faster heart rates (186 vs. 155 beats per minute [bpm]),
and were more likely to present first to an emergency room (69 vs.
30%). The age at tachycardia onset is higher for AVNRT (32 plus
or minus 18 years) than for AVRT (23 plus or minus 14 years) (14,15).
Hospitalization
statistics for supraventricular arrhythmias are summarized in Tables
1 and 2. Of 144 512 discharges for patients aged more than 65 years
in the 1991 to 1998 U.S. Medicare Provider Analysis and Review (MEDPAR)
files, hospitalizations and discharges for AF or atrial flutter
occurred more frequently with advancing age (3),
peaking in 75- to 84-year-old patients. The Healthcare Cost and
Utilization Project (HCUP-3) database, a large, national inpatient
sample of all payer data collected from diverse U.S. community hospitals
(a 20% sample from 17 states), provides data comparable to MEDPAR
for various supraventricular arrhythmia subsets (16).
Supraventricular tachycardia hospital length-of-stay (3.1 vs. 4.2
days) and case fatality rates (0.8% vs. 1%) are slightly lower in
the HCUP-3 dataset when compared to MEDPAR. Atrial flutter and PSVT
represented 5.2% and 3.8%, respectively, of 1998 MEDPAR database
admissions for supraventricular arrhythmias or conduction disorders
(3), but only 0.1 to 0.11% of all
1996 HCUP- 3 database hospital admissions (16).
Gender
plays a role in the epidemiology of SVT. Female residents in the
MESA population had a twofold greater rel- ative risk (RR) of PSVT
(RR equals 2.0; 95% confidence interval equals 1.0 to 4.2) compared
to males (10). Fifty- eight percent
(58%) of symptomatic “lone“ PSVT episodes in MESA females
without concomitant structural heart disease occurred in the premenopausal
age group, as compared to only 9% of episodes in women with cardiovascular
disease (10). Women accounted for the majority (64%) of 1999 U.S.
short-stay, nonfederal hospital admissions for PSVT (ICD-9- CM 427.0)
(17).
The
only reported epidemiologic study of patients with atrial flutter
(18) involved a selected sample
of individuals treated in the Marshfield Clinic in predominantly
white, rural mid-Wisconsin. Over 75% of the 58 820 residents and
virtually all health events were included in this population database.
In approximately 60% of cases, atrial flutter occurred for the first
time associated with a specific precipitating event (ie, major surgery,
pneumonia, or acute myocardial infarc- tion). In the remaining patients,
atrial flutter was associated with chronic comorbid conditions (ie,
heart failure, hypertension, and chronic lung disease). Only 1.7%
of cases had no structural cardiac disease or precipitating cause
(lone atrial flutter). The overall incidence of atrial flutter was
0.088%; 58% of these patients also had AF. Atrial flutter alone
was seen in 0.037%. The incidence of atrial flutter increased markedly
with age, from 5 per 100 000 of those more than 50 years old to
587 per 100 000 over age 80. Atrial flutter was 2.5 times more common
in men. If these findings were extrapolated to the general U.S.
population, then approximately 200 000 new cases of atrial flutter
would occur annually, a diagnosis that is made twice as often as
PSVT (19). |
