Paroxysmal supraventricular tachycardia (PSVT) imposes a substantial burden on patients and health care systems. Despite available treatments, a notable gap exists between evidence-based medicine and real-world practice. Acute treatments such as intravenous adenosine require administration in clinical settings. At-home vagal maneuvers are simple and cost-effective yet are often less effective than those administered by health care providers. The pill-in-the-pocket strategy, defined as patient-administered beta blocker or calcium-channel blocker therapy, is limited by delayed onset of action and risk of side-effects, and is not supported by robust clinical evidence or guidelines. Approved in late 2025, etripamil nasal spray represents a promising advancement that may provide a safe, effective, self-administered therapy used outside of health care setting. In this review, we examine the existing evidence and practical limitations of current PSVT treatments and discuss the potential clinical implications of etripamil as a novel, rapidly acting, self-administered therapy for the termination of acute symptomatic PSVT.

Nodoventricular accessory pathways are rare connections between the atrioventricular (AV) node and ventricular myocardium, typically exhibiting decremental conduction and often mimicking AV nodal re-entrant tachycardia. Their diagnosis remains challenging, particularly in the absence of manifest pre-excitation.

Tachycardia-induced cardiomyopathy (TIC) is most commonly associated with atrial fibrillation or atrial flutter, whereas atrioventricular nodal reentrant tachycardia (AVNRT) is rarely implicated because of its typically paroxysmal nature. We present the case of a 69-year-old man with a history of atrial fibrillation who presented with progressive dyspnea and persistent regular narrow-complex tachycardia initially interpreted as atypical atrial flutter with 2:1 atrioventricular conduction. Repeat electrical cardioversion was unsuccessful, and transthoracic echocardiography (TTE) demonstrated a newly reduced left ventricular ejection fraction (LVEF 20%) with global hypokinesis, while ischemic evaluation was negative. Due to refractory tachyarrhythmia and new non-ischemic cardiomyopathy, the patient underwent a comprehensive electrophysiology study with three-dimensional mapping, which revealed inducible typical AVNRT successfully treated with slow pathway modification. Pulmonary vein isolation and cavotricuspid isthmus ablation were additionally performed because of the patient's prior clinical history of atrial fibrillation and suspected atrial flutter. Following ablation, the patient experienced marked symptomatic improvement with recovery of LVEF to 50% at three-month follow-up, consistent with TIC. This case highlights the diagnostic limitations of surface electrocardiography in differentiating supraventricular tachycardias and demonstrates that AVNRT may rarely masquerade as atrial flutter and contribute to reversible cardiomyopathy, emphasizing the importance of an electrophysiology study in establishing a definitive diagnosis and guiding management.

Suspected acute coronary syndrome (ACS) is one of the most common reasons for urgent cardiology evaluation in the emergency department (ED). This study aimed to evaluate the characteristics and outcomes of patients with suspected ACS who were referred for coronary computed tomography angiography (CCTA) in the ED. We retrospectively enrolled consecutive patients who underwent cardiology assessment and CCTA for suspected ACS in the ED from January 2020 through December 2022. The primary endpoint was a composite of major adverse cardiovascular events (MACE) including all-cause death, acute myocardial infarction, or myocardial revascularization. The study included 198 patients, of whom 175 (51% male) had available follow-up data. Elevated high-sensitivity cardiac troponin I (hs-cTnI) was detected in 42% of patients. Compared to those with normal hs-cTnI, patients with elevated hs-cTnI showed a higher prevalence of atrial fibrillation (12% vs 1%; p < 0.001), paroxysmal supraventricular tachycardia (10% vs 0%; p < 0.001), and pericardial effusion (10% vs 2%; p = 0.023), and were more frequently referred for cardiovascular magnetic resonance (19% vs 4%; p < 0.001). Over a median follow-up of 28 months (IQR:18-34), 14 patients (8%) reached the composite endpoint. After adjusting for demographics, ECG data, and hs-cTnI levels, obstructive atherosclerosis in left main (aHR = 18.31, p = 0.004), circumflex (Cx) (aHR = 8.54, p = 0.008), right coronary artery (aHR = 5.22, p = 0.028), moderate atherosclerosis in the left anterior descending artery (aHR = 6.88, p = 0.039) and mild irregularities in the Cx (aHR = 5.86, p = 0.043) were associated with a higher incidence of MACE. Both the presence of high-risk plaque and higher CAD-RADS 2.0 categories were associated with an increased likelihood of in-hospital revascularization and a survival tree model incorporating myocardial injury markers and CCTA findings demonstrated potential utility for risk stratification. In patients with suspected ACS undergoing cardiology assessment in the ED, CCTA may support patient management.