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9.4 SVT in Older Populations

9.4.1. Acute Treatment and Ongoing Management: Recommendation The natural history of SVT is steadily changing because most patients with SVT undergo ablation at a younger age, but in general, the relative proportion of AT is higher in older populations, and AVNRT is more prevalent than AVRT among patients undergoing ablation.49 Atypical atrial flutter and macroreentrant AT are on the rise as consequences of increasing AF ablation in this patient population, yet there are limited outcome data from RCTs for this segment of the population. Therapeutic decisions should be balanced between the overall risks and benefits of the invasive nature of ablation versus long-term commitment to pharmacological therapy. 10 Quality-of-Life Considerations

Patients with SVT may experience recurring symptoms that negatively impact their quality of life. Episodes of tachycardia can cause lightheadedness and syncope, which can become an obstacle to the performance of usual activities of daily living (eg, driving).72 However, there are minimal data on the effect of treatment on the quality of life for patients with SVT. In 1 study that evaluated patients with SVT who underwent ablation or received medical therapy, questionnaires such as the 36-Item Short-Form Health Survey revealed improved quality-of-life scores in several categories, including physical role functioning (perceived disability from physical limitations), general health perceptions (perceived physical and mental health), and emotional role functioning (perceived disability from emotional limitations).540 These improvements, measured at 1 to 5 years of follow-up, were greater in patients who underwent ablation than in those treated with medical therapy. Other literature, using domains from the 36-Item Short-Form Health Survey541–543 and other quality- of-life questionnaires,544–546 suggests that quality of life is improved after ablation for PSVT. However, these data carry important limitations, particularly a lack of an appropriate control group, small sample sizes, and referral bias. Furthermore, patients affected by PSVT carry different experiences. Therefore, firm conclusions cannot be drawn about the effect on quality of life provided by medical or ablation therapy, and no recommendations are provided. See Online Data Supplement 22 for additional data on quality-of-life considerations.

11 Cost-Effectiveness

Given the rising costs of health care, there is a growing enthusiasm for incorporating economic appraisals of available therapies and resources into guidelines. The “2014 ACC/AHA Statement on Cost/Value Methodology in Clinical Practice Guidelines and Performance Measures”6 called for development of Level of Value categories to accompany COR and LOE in future guidelines. Although basing recommendations on a cost-effectiveness approach to therapy is an important goal for the current and future healthcare economy, it also poses considerable challenges. For example, the cost of therapy, available technology, and practice patterns are highly dynamic, and there may

Recommendations for Acute Treatment and Ongoing Management of SVT in Older Populations COR LOE Recommendation

I B-NR 1.  Diagnostic and therapeutic approaches to SVT should be individualized in patients more than 75 years of age to incorporate age, comorbid illness, physical and cognitive functions, patient preferences, and severity of symptoms.66,67,530–538

See Online Data Supplement 20. Data have consistently demonstrated that ablation is highly successful (>95%) in selected older patients.66,67,531–536 Outcomes from 48 medical centers in Germany were reported among 3234 consecutive patients undergoing AVNRT ablation from 2007 to 2010; of the total, 259 patients (8%) were >75 years of age.537 Acute success was achieved in 98.5% of the older patient group, similar to the 2 younger patient groups (98.7% for the group <50 years of age; 98.8% for the group 50 to 75 years of age). In this study, complication rates were low; hemodynamically stable pericardial effusion was observed in 2 of 259 patients (0.8%), and no pacemakers were needed in the older patient group. Similarly, additional studies from older patient cohorts have consistently shown that older patients have more comorbid medical conditions, have a higher incidence of structural heart disease or ischemic heart disease, and have more severe symptoms associated with SVT.530,538,539 A few studies have shown that complications may be slightly higher in older patients than in younger patients, although the overall complications are low and acceptable.530,538,539 These ablation outcome data should be balanced with the risks and benefits of pharmacological therapy when therapeutic options are reviewed with older patients.

Figure 22. Acute treatment of SVT in ACHD patients. Colors correspond to Class of Recommendation in Table 1; drugs listed alphabetically. *For rhythms that break or recur spontaneously, synchronized cardioversion is not appropriate. ACHD indicates adult congenital heart disease; IV, intravenous; and SVT, supraventricular tachycardia.

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