Narrow complex tachycardia resident survival guide: Difference between revisions

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__NOTOC__
__NOTOC__
{{CMG}}; {{AE}} {{Hilda}}; {{TS}}; {{Rim}}
{{CMG}}; {{AE}} {{Hilda}}; {{TS}}; {{Rim}}; {{AM}}


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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Narrow complex tachycardia resident survival guide#Causes|Causes]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Narrow complex tachycardia resident survival guide#Causes|Causes]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Narrow complex tachycardia resident survival guide#Management|Management]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Narrow complex tachycardia resident survival guide#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Narrow complex tachycardia resident survival guide#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Narrow complex tachycardia resident survival guide#Treatment|Treatment]]
: [[Narrow complex tachycardia resident survival guide#Initial Treatment|Initial]]
: [[Narrow complex tachycardia resident survival guide#Treatment of Specific Supraventricular Arrhythmia|Specific]]
|-
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Narrow complex tachycardia resident survival guide#Do's|Do's]]
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Narrow complex tachycardia resident survival guide#Do's|Do's]]
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==Overview==
==Overview==
Narrow complex tachycardia (NCT) is characterized by heart rate > 100 beats per minute and QRS complex of duration < 120 milliseconds.  The NCT may originate in the [[sinus node]], the atria, the [[AV node]], the [[His bundle]], or combination of these tissues causing rapid activation of the ventriclesDiagnosis of NCT is established by surface [[ECG]] in correlation with history and physical examination.  Hemodynamically unstable patients should receive urgent [[cardioversion]].
Narrow complex tachycardia is characterized by a [[heart rate]] > 100 beats per minute and a [[QRS complex]] of a duration < 120 milliseconds.  Narrow complex tachycardia may originate in the [[sinus node]], [[atrium|atria]], [[AV node]], [[bundle of His]], or a combination of these tissues.  The diagnosis of narrow complex tachycardia is based on the [[ECG]] findings.  Hemodynamically unstable patients should receive urgent [[Cardioversion|synchronized cardioversion]].


==Causes==
==Causes==
===Life Threatening Causes===
===Life Threatening Causes===
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
* [[Wolff-Parkinson-White syndrome]]
* [[Wolff-Parkinson-White syndrome]] ([[AVRT|orthodromic atrioventricular reentrant tachycardia]])
* [[VT]]
* [[Ventricular tachycardia|Idiopathic fascicular ventricular tachycardia]]


===Common Causes===
===Common Causes===
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* [[Atrial flutter]]
* [[Atrial flutter]]
* [[Atrial tachycardia]]
* [[Atrial tachycardia]]
* [[AVNRT]]
* [[AVRT|Atrioventricular reentrant tachycardia]] ([[AVRT]]) <br>
* [[AVRT]]
* [[AV nodal reentrant tachycardia]] ([[AVNRT]]) <br>
 
Click '''[[Supraventricular tachycardia causes|here]]''' for the complete list of causes.


==Management==
==FIRE: Focused Initial Rapid Evaluation==
===Initial Management===
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.
Shown below is an algorithm summarizing the initial management of narrow complex tachycardia according to the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias.<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher =  | date =  | accessdate = 15 August 2013 }}</ref>


<span style="font-size:85%"> '''ECG:''' electrocardiogram; '''SVT:''' supraventricular tachycardia </span>
<span style="font-size:85%">Boxes in the red color signify that an urgent management is needed.</span>
 
{{Family tree/start}}
{{familytree | | | | | | | A01 | | |A01=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Identify cardinal findings that increase the pretest probability of narrow complex tachycardia''' <br>❑ [[Palpitations]] <br>❑ [[Heart rate]] > 100 beats/min <br>❑ [[QRS complex]] < 120 ms </div> <br> }}
{{familytree | | | | | | | |!| | | }}
{{familytree | | | | | | | B01 | | |B01=<div style="float: left; text-align: left; width: 18em; padding:1em;">'''Does the patient have any of the following findings that require urgent cardioversion?''' <br>
❑ Hemodynamic instability
:❑ [[Hypotension]]
:❑ [[Cold extremities]]
:❑ [[Cyanosis|Peripheral cyanosis]]
:❑ [[Mottling]]
:❑ [[Altered mental status]]
❑ [[Chest discomfort]] suggestive of [[ischemia]] <br>
❑ [[Heart failure|Decompensated heart failure]]<ref name="ACLS">{{Cite web  | last =  | first =  | title = Part 8: Adult Advanced Cardiovascular Life Support | url = http://circ.ahajournals.org/content/122/18_suppl_3/S729.full | publisher =  | date =  | accessdate = 3 April 2014 }}</ref></div>}}
{{familytree | | | |,|-|-|-|^|-|-|-|.| | | | | | | | | | | }}
{{familytree | | | B01 | | | | | | B02 | | | | | | | | | | |B01=<div style="float: left; text-align: left; background: #FA8072; width: 15em; padding:1em;"> {{fontcolor|#F8F8FF| ❑ '''Yes'''}} </div>|B02=❑ '''No'''}}
{{familytree | | | |!| | | | | | | |!| | | | | | | | |}}
{{familytree | | | C01 | | | | | | C02 | | | | C01=<div style="float: left; text-align: left; background: #FA8072; width: 15em; padding:1em;"> {{fontcolor|#F8F8FF| ❑ Urgent [[synchronized cardioversion|<span style="color:white;">synchronized cardioversion</span>]]<br>
:❑ Narrow regular rhythm: 50-100 Joules
:❑ Narrow irregular rhythm: 120-200 Joules biphasic or 200 Joules monophasic}}<ref name="ACLS">{{Cite web  | last =  | first =  | title = Part 8: Adult Advanced Cardiovascular Life Support | url = http://circ.ahajournals.org/content/122/18_suppl_3/S729.full | publisher =  | date =  | accessdate = 3 April 2014 }}</ref><ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher =  | date =  | accessdate = 15 August 2013 }}</ref> </div> |C02=<div style="float: left; text-align: left; width: 15em; padding:1em;">  ❑ '''[[Narrow complex tachycardia resident survival guide#Complete Diagnostic Approach|Continue with the complete diagnostic approach below]]''' </div>}}
{{familytree | | | |!| | | | | }}
{{familytree | | | D01 | | | | D01= <div style="float: left; text-align: left; width: 15em; padding:1em;">❑ '''[[Narrow complex tachycardia resident survival guide#Complete Diagnostic Approach|After the stabilization of the patient, continue with the complete diagnostic approach below]]''' </div>}}
{{Family tree/end}}
<br>
 
==Complete Diagnostic Approach==
A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher =  | date =  | accessdate = 15 August 2013 }}</ref><br>
<span style="font-size:85%">'''Abbreviations:''' '''ECG:''' electrocardiogram; '''SVT:''' Supraventricular tachycardia; '''ms''': milliseconds; '''AV''':  atrioventricular; '''AVNRT''': atrioventricular nodal reciprocating tachycardia; '''MAT''': multifocal atrial tachycardia; '''ms''': milliseconds; '''PJRT''': permanent form of junctional reciprocating tachycardia; '''RP interval''': is the time between anterograde ventricular activation (R wave) and retrograde atrial activation ([[P wave]]) </span>


{{familytree/start}}
{{familytree/start}}
{{familytree | | | | | | | A01 | | A01=<div style="float: left; text-align: left; width: 27em; padding:1em;"> '''Characterize the symptoms:'''<br>
{{familytree | | | | | | | | A01 | | A01=
❑ Asymptomatic (most common presentation) <br> ❑ [[Palpitations]]<br> ❑ [[Dyspnea]] <br> ❑ [[Fatigue]] <br> ❑ [[Chest pain|Chest discomfort]] <br> ❑ [[Lightheadedness]]<br> ❑ [[Syncope]] <br> ❑ [[Polyuria]] <br>
<div style="float: left; text-align: left; width: 27em; padding:1em;"> '''Characterize the symptoms:'''<br>
</div> }}
❑ Asymptomatic (most common presentation) <br> ❑ [[Palpitations]]<br> ❑ Sensation of a pause followed by a strong heart beat (suggestive of premature beats) <br> ❑ [[Dyspnea]] <br> ❑ [[Fatigue]] <br> ❑ [[Chest pain|Chest discomfort]] <br> ❑ [[Lightheadedness]]<br> ❑ [[Syncope]] <br> ❑ [[Polyuria]] <br>
{{familytree | | | | | | | |!| | | }}
'''Characterize the timing of the symptoms:'''<br>
{{familytree | | | | | | | B01 | | | B01= <div style="float: left; text-align: left; width: 27em; padding:1em;"> '''Identify possible triggers:'''<br>
❑ Onset <br>
:❑ First episode
:❑ Recurrent
❑ Duration <br>
❑ Frequency<br>
❑ Termination of the episode
:❑ Spontaneous
:❑ Medication use
:❑ Not terminated</div>}}
{{familytree | | | | | | | | |!| | | }}
{{familytree | | | | | | | | B01 | | | B01= <div style="float: left; text-align: left; width: 27em; padding:1em;"> '''Identify possible triggers:'''<br>
<table>
<table>
<tr class="v-firstrow"><td>❑ [[Infection]]</td><td>❑ [[Caffeine]]</td><td>❑ [[Alcohol]]</td></tr>
<tr class="v-firstrow"><td>❑ [[Infection]]</td><td>❑ [[Caffeine]]</td><td>❑ [[Alcohol]]</td></tr>
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<tr><td>❑ [[Hyperthyroidism]]</td><td> ❑ [[Hypoxia]]</td><td> ❑ [[Acidosis]] </td></tr>
<tr><td>❑ [[Hyperthyroidism]]</td><td> ❑ [[Hypoxia]]</td><td> ❑ [[Acidosis]] </td></tr>
<tr><td>❑ [[Hypokalemia]]</td><td> ❑ [[Hyperkalemia]]</td><td> ❑ [[Hypoglycemia]] </td></tr>
<tr><td>❑ [[Hypokalemia]]</td><td> ❑ [[Hyperkalemia]]</td><td> ❑ [[Hypoglycemia]] </td></tr>
<tr><td>❑ [[Hypothermia]]</td><td> ❑ [[Toxins]]</td></tr>
<tr><td>❑ [[Hypothermia]]</td><td> ❑ [[Toxins]]</td><td>❑ [[Pulmonary embolism]] </tr>
<tr><td>❑ [[Pulmonary embolism]]</td><td> ❑ [[Coronary thrombosis]]</td><td> ❑ [[Trauma]] </td></tr></table>
<tr><td>❑ [[Coronary thrombosis]]</td><td> ❑ [[Trauma]] </td></tr></table>
</div>}}
{{familytree | | | | | | | |!| | | }}
{{familytree | | | | | | | C01 | | C01= <div style="float: left; text-align: left; width: 27em; padding:1em;">
'''Differential Diagnosis''' <br>
❑ [[AV nodal reentrant tachycardia]] ([[AVNRT]]) <br>
❑ [[AVRT|Atrioventricular reentrant tachycardia]] ([[AVRT]]) <br>
❑ Junctional tachycardia <br>
❑ [[Sinus tachycardia]] <br>
❑ Inappropriate sinus tachycardia <br>
❑ [[SANRT|Sinus node re-entry tachycardia]] <br>
❑ Intraatrial reentrant tachycardia (IART) <br>
❑ Atrial tachycardia <br>
❑ [[Multifocal atrial tachycardia]] <br>
❑ [[Atrial fibrillation]] <br>
❑ [[Atrial flutter]] <br>
</div>}}
</div>}}
{{familytree | | | | | | | |!| | | }}
{{familytree | | | | | | | | |!| | | }}
{{familytree | | | | | | | C01 | | C01= <div style="float: left; text-align: left; width: 27em; padding:1em;">
{{familytree | | | | | | | | C01 | | C01= <div style="float: left; text-align: left; width: 27em; padding:1em;">
'''Examine the patient:'''<br>
'''Examine the patient:'''<br>
----
'''General appearance'''<br>
❑ Well appearing
----
'''Vitals'''<br>
'''Vitals'''<br>
❑ [[Pulse]]<br>
❑ [[Pulse]]<br>
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:❑ Rhythm  <br>  
:❑ Rhythm  <br>  
::❑ Regular <br>
::❑ Regular <br>
::❑ Regular irregular <br>
::❑ Irregular ([[atrial fibrillation]], [[MAT]]) <br>  
::❑ Irregularly irregular <br>  
:❑ Strength  <br>  
:❑ Strength  <br>  
::❑ Weak  <br>  
::❑ Weak  <br>  
::❑ Alternating in strength <br>   
::❑ Alternating in strength ([[atrial fibrillation]]) <br>   
❑ [[Respiration]]<br>
❑ [[Respiration]]<br>
:❑ [[Tachypnea]]   <br>  
: ❑ [[Tachypnea]]<br>
❑ [[Blood pressure]]<br>
❑ [[Blood pressure]]<br>
:❑ [[Hypotension]] (in hemodynamically unstable patients due to decreased ventricular filling)   <br>   
:❑ [[Normal]] (typical)<br>
----
:❑ [[Hypotension]] (in hemodynamically unstable patients)<br>   
'''Neck'''<br>
'''Neck'''<br>
:❑ Elevated [[jugular venous pressure]] (as in some cases of [[atrial fibrillation]])<br>  
:❑ Absent [[a wave]] in [[jugular venous pressure]] (in [[atrial fibrillation]])<br>  
----
'''Cardiovascular examination'''<br>
'''Cardiovascular examination'''<br>
❑ Auscultation <br>
❑ Auscultation <br>
:❑ [[Heart sounds]]: rapid regualr or irregular pulse depending on the type of arrhythmia and sometimes associated with murmurs if there is an underlying cardiac disease (eg, [[aortic stenosis]]) <br>
:❑ [[Heart sounds]]
::❑ Rapid regular or irregular beats <br>
::❑ Murmurs (suggestive of valvular diseases)<br>
</div>}}
</div>}}
{{familytree | | | | | | | |!| | | }}
{{familytree | | | | | | | | |!| | | }}
{{familytree | | | | | | | A01 | | | | | A01= <div style="float: left; text-align: left; width: 27em; padding:1em;"> ❑ Assess hemodynamic stability<br>
{{familytree | | | | | | | | A01 | | | | | A01= <div style="float: left; text-align: left; width: 27em; padding:1em;">
:❑ Monitor the [[blood pressure]]
:❑ Monitor the [[heart rate]]
❑ Order and monitor the [[ECG]]<br>
❑ Order and monitor the [[ECG]]<br>
❑ Assess and support airway, breathing and circulation ([[ABC]]) <br>
<span style="color:red">Perform urgent cardioversion in unstable patients</span>
❑ Give oxygen if needed <br>
</div>}}
</div>}}
{{familytree | | | | | | | |!| | | }}
{{familytree | | | | | | | | |!| | | }}
{{familytree | | | |,|-|-|-|^|-|-|-|-|.| | | | | | | | | | | }}
{{familytree | | | | | | | | A01 |A01=<div style="float: left; text-align: left; padding:1em;"> '''Narrow QRS tachycardia'''<br>❑ [[Heart rate]] > 100 beats/min <br> [[QRS complex]] < 120 ms </div>}}
{{familytree | | | K02 | | | | | | | K05 | | | | | | | | | | |K02=❑ Unstable patient|K05=❑ Stable patient}}
{{familytree | |,|-|^|-|.| | | |,|-|-|^|-|-|-|-|.| | | | |}}
{{familytree | K03 | | K04 | | D01 | | | | | | D02 | | | |K03=<div style="float: left; text-align: left; height: em; 17width: em; padding:1em;">'''If the rythm isn't sinus tachycardia''':<br> <span style="color:red">Urgent cardioversion </span> </div>|K04=<div style="float: left; text-align: left; height: em; 17width: em; padding:1em;">❑ '''If the rythm is sinus tachycardia''': <br> Focus your treatment on the underlying condition. If it is due to [[cardiac ischemia]] or [[aortic stenosis]], control [[heart rate]] by IV [[metoprolol]] at the rate of 5 mg/2 minutes till full control or till the maximum of 15 mg, then shift to oral regimen.<br> Don't adminster [[beta blockers]] if the patient has significant [[bradycardia]] (<50 beats per minute)</div>|D01='''Documented arrhythmia'''| D02= '''Undocumented arrhythmia'''<br> ([[ECG]] is normal)}}
{{familytree | | | | | | | | | |!| | | | | |,|-|^|.| | | | | }}
{{familytree | | | | | | | | | E03 | | | | E01 | | E02 | |E01=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''History suggestive of extra premature beats'''<br>
❑ Sensation of a pause followed by a strong heart beat OR<br>
❑ Irregularities in heart rhythm </div> |E02=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''History suggestive of paroxysmal arrhythmia'''<br>
❑ Regular palpitations with sudden onset and termination
</div> |E03=<div style="float: left; text-align: left; width: 15em; padding:1em;">❑ Confirm diagnosis of narrow QRS complex tachycardia (heart rate > 100 beats per minute associated with a QRS complex duration < 120 milliseconds)<br> ❑ Identify and treat [[SVT]] </div>|E04=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Unstable patient'''</div>}}
{{familytree | | | | | | | | | | | | | | | |!| | | |!| | | }}
{{familytree | | | | | | | | | | | | | | | F01 | | F02 | |F01=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''Rule out the following:'''<br>
❑ [[Caffeine]]<br>❑ [[Alcohol]]<br>❑ [[Nicotine]]<br>❑ [[Recreational drugs]]<br>❑ [[Hyperthyroidism]]</div>|F02=<div style="float: left; text-align: left; width: 15em; padding:1em;">❑ Refer for an invasive electrophysiological study AND/OR<br>❑ [[Catheter ablation]]<br> ❑ Educate about [[vagal maneuvers]]<br> ❑ Consider [[beta blocker]]</div>}}
{{familytree/end}}
<br>
 
===Identification of the Rhythm on ECG===
Shown below is an algorithm summarizing the approach to differentiate various types of narrow complex tachycardia according to the 2003 guidelines issued by ACC/AHA/ESC for the management of patients with supraventricular arrhythmias.<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher =  | date =  | accessdate = 15 August 2013 }}</ref> <br>
<span style="font-size:85%">'''Abbreviations:''' '''AV''':  atrioventricular; '''AVNRT''': atrioventricular nodal reciprocating tachycardia; '''MAT''': multifocal atrial tachycardia; '''ms''': milliseconds; '''PJRT''': permanent form of junctional reciprocating tachycardia </span>
 
{{familytree/start |summary=PE diagnosis Algorithm}}
{{familytree | | | | | | | | A01 |A01=<div style="float: left; text-align: left; padding:1em;"> '''Narrow QRS tachycardia'''<br>❑ Heart rate > 100 beats/min <br> ❑ QRS duration < 120 ms </div>}}
{{familytree | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | | B01 | | | | | | |B01=❑ Determine the regularity of rhythm}}
{{familytree | | | | | | | | B01 | | | | | | |B01=❑ Determine the regularity of the rhythm}}
{{familytree | | | |,|-|-|-|-|^|-|-|-|-|.| | | }}
{{familytree | | | |,|-|-|-|-|^|-|-|-|-|.| | | }}
{{familytree | | | C01 | | | | | | | | C02 | | |C01='''Regular rhythm'''|C02='''Irregular rhythm'''}}
{{familytree | | | C01 | | | | | | | | C02 | | |C01='''Regular rhythm'''|C02='''Irregular rhythm'''}}
{{familytree | | | |!| | | | | | | | | |!| }}
{{familytree | | | |!| | | | | | | | | |!| }}
{{familytree | | | D01 | | | | | | | | D02 |D01=<div style="float: left; text-align: left; padding:1em;"> '''Consider the following causes:'''<br>
{{familytree | | | D01 | | | | | | | | D02 |D01=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''Consider the following causes:'''<br>
❑ [[AVRT]]<br>
❑ [[AVRT]]<br>
❑ [[AVNRT]]<br>
❑ [[AVNRT]]<br>
❑ [[Atypical AVNRT]]<br>
❑ [[Atypical AVNRT]]<br>
❑ [[Atrial tachycardia]]<br>
❑ [[Atrial tachycardia]]<br>
❑ [[Atrial flutter]]</div>|D02=<div style="float: left; text-align: left; padding:1em;">'''Consider the following causes:'''<br>
❑ [[Atrial flutter]]</div>|D02=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Consider the following causes:'''<br>
❑ [[Atrial fibrillation]]<br>
❑ [[Atrial fibrillation]]<br>
❑ Atrial tachycardia/[[atrial flutter|flutter]] with variable AV conduction<br>
[[Atrial tachycardia]]/[[atrial flutter|flutter]] with variable AV conduction<br>
❑ [[MAT]]</div>}}
❑ [[MAT]]</div>}}
{{familytree | | | |!| | | | | | | | | |!| | |}}
{{familytree | | | |!| | | | | | | | | |!| | |}}
{{familytree | | | Y01 | | | | | | | | Y02 | |Y01=❑ '''Determine P wave morphology'''|Y02=❑ '''Determine P wave morphology'''}}
{{familytree | | | Y01 | | | | | | | | Y02 | |Y01=❑ '''Determine P wave morphology'''|Y02=❑ '''Determine P wave morphology'''}}
{{familytree | |,|-|^|-|.| | | |,|-|-|-|+|-|-|-|.| | | | |}}
{{familytree | |,|-|^|-|.| | | |,|-|-|-|+|-|-|-|.| | | | |}}
{{familytree | E01 | | E02 | | E03 | | E04 | | E05 | | | | |E01=<div style="float: left; text-align: left; padding:1em;">❑ P waves are not visible </div>
{{familytree | E01 | | E02 | | E03 | | E04 | | E05 | | | | |E01=<div style="float: left; text-align: left; padding:1em;">❑ [[P wave]]s are not visible </div>
|E02=❑ P waves are visible|E03=❑  > 3 P wave morphologies|E04=❑ Absent P waves |E05=❑ Sawtooth appearance of P waves}}
|E02=❑ [[P wave]]s are visible|E03=<div style="float: left; width: em; padding:1em;"align=center>❑  > 3 [[P wave]] morphologies</div>|E04=❑ Absent [[P wave]]s |E05=❑ Sawtooth appearance of [[P wave]]s}}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | | |}}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | | |}}
{{familytree | F02 | | F01 | | F03 | | F04 | | F05 | | | |F01= ❑ '''Determine if atrial rate is greater than ventricular rate'''|F02=❑ Consider [[AVNRT]]|F04=[[Atrial fibrillation]]|F03=[[MAT]]|F05=[[Atrial flutter]]}}
{{familytree | F02 | | F01 | | F03 | | F04 | | F05 | | | |F01= ❑ '''Determine if atrial rate is greater than ventricular rate'''|F02=❑ Consider [[AVNRT]]|F04=❑ Consider [[atrial fibrillation]]|F03=❑ Consider [[MAT]]|F05=❑ Consider [[atrial flutter]]}}
{{familytree | | | |,|-|^|-|.| | | | | | | | | | |}}
{{familytree | | | |,|-|^|-|.| | | | | | | | | | |}}
{{familytree | | | G01 | | G02 | | | | | | | | | G01=Atrial rate > ventricular rate |G02= Atrial rate ≤ ventricular rate}}
{{familytree | | | G01 | | G02 | | | | | | | | | G01=[[Atria|Atrial]] rate > [[ventricle|ventricular]] rate |G02= [[Atria|Atrial]] rate ≤ [[ventricle|ventricular]] rate}}
{{familytree | | | |!| | | |!| | | | | | | | | | }}
{{familytree | | | |!| | | |!| | | | | | | | | | }}
{{familytree | | | H01 | | H02 | | | | | | | | | H01= <div style="float: left; text-align: left; 10em; padding:1em;">'''Consider the following causes:''' <br> ❑ [[Atrial flutter]] <br>❑ [[atrial tachycardia]] </div> |H02=❑ Determine if RP interval > PR interval}}
{{familytree | | | H01 | | H02 | | | | | | | | | H01= <div style="float: left; text-align: left; 10em; padding:1em;">'''Consider the following causes:''' <br> ❑ [[Atrial flutter]] <br>❑ [[Atrial tachycardia]] </div> |H02=❑ Determine if RP interval > [[PR interval]]}}
{{familytree | | | | | |,|-|^|-|-|-|.| | }}
{{familytree | | | | | |,|-|^|-|-|-|.| | }}
{{familytree | | | | | I01 | | | | I02 | | | | | | | | | I01= RP < PR|I02= RP > PR}}
{{familytree | | | | | I01 | | | | I02 | | | | | | | | | I01= RP < PR|I02= RP > PR}}
Line 168: Line 169:
|K02=<div style="float: left; text-align: left; padding:1em;">'''Consider the following causes:''' <br>❑ [[AVRT]]<br>❑ [[AVNRT]]<br>❑ [[Atrial tachycardia]] </div>}}
|K02=<div style="float: left; text-align: left; padding:1em;">'''Consider the following causes:''' <br>❑ [[AVRT]]<br>❑ [[AVNRT]]<br>❑ [[Atrial tachycardia]] </div>}}
{{familytree/end}}
{{familytree/end}}
<br>
===ECG Examples===
Shown below is a table depicting the [[ECG]] findings of the different types of narrow complex tachycardia.<ref name="pmid16525141">{{cite journal| author=Delacrétaz E| title=Clinical practice. Supraventricular tachycardia. | journal=N Engl J Med | year= 2006 | volume= 354 | issue= 10 | pages= 1039-51 | pmid=16525141 | doi=10.1056/NEJMcp051145 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16525141  }} </ref><ref name="pmid23050527">{{cite journal| author=Link MS| title=Clinical practice. Evaluation and initial treatment of supraventricular tachycardia. | journal=N Engl J Med | year= 2012 | volume= 367 | issue= 15 | pages= 1438-48 | pmid=23050527 | doi=10.1056/NEJMcp1111259 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23050527  }} </ref>


Note: Patients with focal junctional tachycardia may mimic the pattern of slow-fast [[AVNRT]] and may show AV dissociation and/or marked irregularity in the junctional rate.<br>
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
<br>
|-
| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Type of [[Arrhythmia]]'''||style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''[[EKG]]''' (lead II)† ||style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Clues'''
|-
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left| '''[[Sinus tachycardia]]'''||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|[[Image:Sinus tachycardia.png|300px|link=Narrow complex tachycardia resident survival guide]]||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''Onset and termination''': gradual<br> '''Rhythm''': regular<br> '''Rate''': >220 minus the age of the patient <br> '''Response to adenosine''': transient decrease of the rate
|-
|style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''[[Atrial fibrillation]]'''||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|[[Image:atrial fibrillation.png|300px|link=Narrow complex tachycardia resident survival guide]]||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''Onset and termination''': abrupt <br> '''Rhythm''': irregular <br> '''Rate''':100-180 bpm <br> '''Response to adenosine''': transient decrease of the ventricular rate
|-
|style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''[[Atrial flutter]]'''||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|[[Image:atrial flutter.png|300px|link=Narrow complex tachycardia resident survival guide]]||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''Onset and termination''': abrupt <br> '''Rhythm''': regular<br> '''Rate''': >150 bpm <br> '''Response to adenosine''': transient decrease of the rate <br> Presence of saw-tooth appearance
|-
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''[[AVNRT]]'''||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|[[Image:AVNRT.png|300px|link=Narrow complex tachycardia resident survival guide]]||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''Onset and termination''': abrupt <br> '''Rhythm''': regular<br> '''Rate''': 150-250 bpm <br> '''Response to adenosine''': termination of the arrhythmia
|-
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''[[AVRT]]'''||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|[[Image:AVRT.png|300px|link=Narrow complex tachycardia resident survival guide]]||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left| '''Onset and termination''': abrupt <br> '''Rhythm''': regular<br> '''Rate''': 150-250 bpm <br> '''Response to adenosine''': termination of the arrhythmia
|-
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''[[Focal atrial tachycardia]]'''||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|[[Image:focal atrial tachycardia.png|300px|link=Narrow complex tachycardia resident survival guide]]|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''Onset and termination''': abrupt <br> '''Rhythm''': regular<br> '''Rate''': 150-250 bpm
|-
|style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''[[Junctional tachycardia|Nonparoxysmal junctional tachycardia]]'''||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|[[Image:JTS.png|300px|link=Narrow complex tachycardia resident survival guide]]|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''Rhythm''': regular <br> Retrograde P wave<br> Most commonly due to ischemia or digitalis toxicity
|-
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''[[Multifocal atrial tachycardia]]'''||style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|[[Image:MAT.png|300px|link=Narrow complex tachycardia resident survival guide]]|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|'''Onset and termination''': gradual<br> '''Rhythm''': irregular<br> '''Rate''': 100-150 bpm <br> '''Response to adenosine''': no effect<br>3 different [[P wave]] morphologies
|-
|}
† [[ECG]] strips are courtesy of ECGpedia.


===Short Term Treatment of SVT in a Hemodynamically Stable Patient===
==Treatment==
Shown below is an algorithm summarizing the initial management of narrow complex tachycardia according to the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias.<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher =  | date =  | accessdate = 15 August 2013 }}</ref> <br>
===Initial Treatment===
Shown below is an algorithm summarizing the management of narrow complex tachycardia according to the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias.<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher =  | date =  | accessdate = 15 August 2013 }}</ref> <br>
<span style="font-size:85%">'''Abbreviations:''' '''AF''':  atrial fibrillation; '''AV''': atrioventricular; '''AVNRT''': atrioventricular nodal reciprocating tachycardia; '''AVRT''': atrioventricular reciprocating tachycardia; '''BBB''': bundle-branch block; '''ECG''': electrocardiography; ''' IV''': intravenous; '''LV''': left ventricle; '''SVT''': supraventricular tachycardia; '''VT''': ventricular tachycardia </span>
<span style="font-size:85%">'''Abbreviations:''' '''AF''':  atrial fibrillation; '''AV''': atrioventricular; '''AVNRT''': atrioventricular nodal reciprocating tachycardia; '''AVRT''': atrioventricular reciprocating tachycardia; '''BBB''': bundle-branch block; '''ECG''': electrocardiography; ''' IV''': intravenous; '''LV''': left ventricle; '''SVT''': supraventricular tachycardia; '''VT''': ventricular tachycardia </span>
{{familytree/start}}
{{familytree/start}}
{{familytree | | | D01 | | D01=<div style="float: left; text-align: left; width: 35em; padding:1em;">'''Acute management:'''<br>
{{familytree | | | A01 | | A01= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the patient have any of the following findings that require urgent cardioversion?''' <br>
❑ Perform vagal maneuvers ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])<br>
❑ Hemodynamic instability
:❑ [[Hypotension]]
:❑ [[Cold extremities]]
:❑ [[Cyanosis|Peripheral cyanosis]]
:❑ [[Mottling]]
:❑ [[Altered mental status]]
❑ [[Chest discomfort]] suggestive of [[ischemia]] <br>
❑ [[Heart failure|Decompensated heart failure]] </div>}}
{{familytree | |,|-|^|-|.| | }}
{{familytree | B01 | | B02 | B01= Yes | B02= No}}
{{familytree | |!| | | |!| | | | | }}
{{familytree | C01 | | C02 | | | | C01= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''Urgent synchronized cardioversion''' <br>
❑ Narrow regular rhythm: 50-100 J <br>
❑ Narrow irregular rhythm: 120-200 J biphasic or 200 J monophasic </div>| C02= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''Acute management:'''<br>
❑ Perform [[vagal maneuvers]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])<br>
: ❑ [[Valsalva maneuver]]<br>
: ❑ [[Valsalva maneuver]]<br>
: ❑ Carotid massage<br>
: ❑ [[Carotid sinus massage]]<br>
 
<span style="font-size:85%;color:red">Carotid massage is contraindicated in case of prior MI, transient ischemic attack or stroke within the last three months, previous history of ventricular fibrillation or fibrillation tachycardia, and in case of carotid bruits.</span><ref name="www.aafp.org">{{Cite web  | last =  | first =  | title = Tips From Other Journals - American Family Physician | url = http://www.aafp.org/afp/2001/0901/p848.html | publisher =  | date =  | accessdate = 3 April 2014 }}</ref><br>
❑ Monitor [[ECG]] continuously</div>}}
❑ Monitor [[ECG]] continuously</div>}}
{{familytree | | | |!| | | | |}}
{{familytree | | | | | |!| | | | |}}
{{familytree | | | D02 | | |D02=<div style="float: left; text-align: left; width: 35em; padding:1em;">'''If vagal maneuvers fail:'''<br>
{{familytree | | | | | D02 | | | | D02=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''If vagal maneuvers fail:'''<br>
❑ Administer IV [[adenosine]]([[ACC AHA guidelines classification scheme|Class I, level of evidence A]])<br>
❑ Administer IV [[adenosine]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]])<br>
:❑ First dose: 6 mg rapid IV push, followed by 20 mL of [[normal saline]] bolus
:❑ First dose: 6 mg rapid IV push, followed by 20 mL of [[normal saline]] bolus
:❑ Second dose: 12 mg (if no response in 1-2 min)<ref name="pmid16525141">{{cite journal| author=Delacrétaz E| title=Clinical practice. Supraventricular tachycardia. | journal=N Engl J Med | year= 2006 | volume= 354 | issue= 10 | pages= 1039-51 | pmid=16525141 | doi=10.1056/NEJMcp051145 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16525141  }} </ref>
:❑ Second dose: 12 mg (if no response in 1-2 min)
 
<span style="font-size:85%;color:red">Adenosine is contraindicated in cardiac transplant patients.  Use adenosine with caution in severe obstructive lung disease.</span><ref name="pmid16525141">{{cite journal| author=Delacrétaz E| title=Clinical practice. Supraventricular tachycardia. | journal=N Engl J Med | year= 2006 | volume= 354 | issue= 10 | pages= 1039-51 | pmid=16525141 | doi=10.1056/NEJMcp051145 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16525141  }} </ref>
❑ Monitor [[ECG]] continuously </div>}}
❑ Monitor [[ECG]] continuously </div>}}
{{familytree | | | |!| | | }}
{{familytree | | | | | |!| | | }}
{{familytree | | | C01 | |C01=<div style="float: left; text-align: left; width: 35em; padding:1em;">❑ Assess changes on [[ECG]] following adenosine administration
{{familytree | | | | | D03 | |D03=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''If adenosine fails, administer ONE of the following:'''<br>
<table class="wikitable">
<tr class="v-firstrow"><th>Changes on ECG</th><th> Possible causes</th></tr>
<tr><td>'''No change'''</td><td>❑ Inadequate delivery of the medication<br>❑ Inadequate dose <br> ❑ [[VT]] </td></tr>
<tr><td>'''Gradual slowing then re-acceleration of rate'''</td><td>❑ [[Sinus tachycardia]] <br>
❑ Focal AT <br>
❑ Nonparoxysmal junctional tachycardia </td></tr>
<tr><td>'''Abrupt termination'''</td><td>❑ [[AVNRT]] <br>❑ [[AVRT]] <br> ❑ Sinus node re-entry <br> ❑ Focal AT</td></tr>
<tr><td>'''Persisting atrial tachycardia with transient high-grade AV block'''</td><td>❑ [[Atrial flutter]] <br>
❑ [[Atrial tachycardia]] </td></tr>
</table> </div> }}
{{familytree | | | |!| |}}
{{familytree | | | D03 | |D03=<div style="float: left; text-align: left; width: 35em; padding:1em;"> '''If adenosine fails, administer ONE of the following:'''<br>
❑ IV [[verapamil]] 5 mg IV every 3-5 min, maximum 15 mg ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]])<ref name="pmid16525141">{{cite journal| author=Delacrétaz E| title=Clinical practice. Supraventricular tachycardia. | journal=N Engl J Med | year= 2006 | volume= 354 | issue= 10 | pages= 1039-51 | pmid=16525141 | doi=10.1056/NEJMcp051145 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16525141  }} </ref><br>
❑ IV [[verapamil]] 5 mg IV every 3-5 min, maximum 15 mg ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]])<ref name="pmid16525141">{{cite journal| author=Delacrétaz E| title=Clinical practice. Supraventricular tachycardia. | journal=N Engl J Med | year= 2006 | volume= 354 | issue= 10 | pages= 1039-51 | pmid=16525141 | doi=10.1056/NEJMcp051145 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16525141  }} </ref><br>
❑ IV [[diltiazem]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]])
❑ IV [[diltiazem]] ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]])
Line 207: Line 240:
:❑ Maintenance infusion of 5-15 mg/hour<ref name="pmid16525141">{{cite journal| author=Delacrétaz E| title=Clinical practice. Supraventricular tachycardia. | journal=N Engl J Med | year= 2006 | volume= 354 | issue= 10 | pages= 1039-51 | pmid=16525141 | doi=10.1056/NEJMcp051145 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16525141  }} </ref>
:❑ Maintenance infusion of 5-15 mg/hour<ref name="pmid16525141">{{cite journal| author=Delacrétaz E| title=Clinical practice. Supraventricular tachycardia. | journal=N Engl J Med | year= 2006 | volume= 354 | issue= 10 | pages= 1039-51 | pmid=16525141 | doi=10.1056/NEJMcp051145 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16525141  }} </ref>
❑ IV [[beta blocker]] ([[ACC AHA guidelines classification scheme|Class IIb, level of evidence C]])<br>
❑ IV [[beta blocker]] ([[ACC AHA guidelines classification scheme|Class IIb, level of evidence C]])<br>
:[[Metoprolol]] <br>
:[[Metoprolol]] <br>
:❑ 5 mg over 2 minutes
::❑ 5 mg over 2 minutes
:❑ Up to 3 doses within 15 minutes
::❑ Up to 3 doses within 15 minutes
:[[Esmolol]] <br>
:[[Esmolol]] <br>
:❑ 250-500 μg/kg over 1 minute
::❑ 250-500 μg/kg over 1 minute
:❑ Maintenance with 50-200 μg/kg over 4 minutes (if needed)
::❑ Maintenance with 50-200 μg/kg over 4 minutes (if needed)
:[[Propranolol]] <br>
:[[Propranolol]] <br>
:❑ 0.15 mg/kg over 2 minutes<ref name="pmid16525141">{{cite journal| author=Delacrétaz E| title=Clinical practice. Supraventricular tachycardia. | journal=N Engl J Med | year= 2006 | volume= 354 | issue= 10 | pages= 1039-51 | pmid=16525141 | doi=10.1056/NEJMcp051145 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16525141  }} </ref>
::❑ 0.15 mg/kg over 2 minutes<ref name="pmid16525141">{{cite journal| author=Delacrétaz E| title=Clinical practice. Supraventricular tachycardia. | journal=N Engl J Med | year= 2006 | volume= 354 | issue= 10 | pages= 1039-51 | pmid=16525141 | doi=10.1056/NEJMcp051145 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16525141  }} </ref>
----
----
❑ Monitor [[ECG]] continuously </div>}}
❑ Monitor [[ECG]] continuously </div>}}
{{familytree | |,|-|^|-|.| | | | | | | |}}
{{familytree | | | |,|-|^|-|.| | | | | | | |}}
{{familytree | F01 | | F02 | | |F01='''Terminated arrhythmia'''|F02='''Persistent arrhythmia'''}}
{{familytree | | | F01 | | F02 | | |F01='''Arrhythmia is terminated'''|F02='''Arrhythmia is persistent'''}}
{{familytree | |!| | | |!| | | }}
{{familytree | | | |!| | | |!| | | }}
{{familytree | G02 | | G01 | |G01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> ❑ Administer AV-nodal-blocking agent AND one of the following<br>
{{familytree | | | G02 | | G01 | |G01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> ❑ Administer AV-nodal-blocking agent AND one of the following<br>
:❑ IV [[ibutilide]]<br>
:❑ IV [[ibutilide]]<br>
 
<span style="font-size:85%;color:red">[[Ibutilide]] is especially indicated for patients with atrial flutter but should not be used in patients with [[ejection fraction]] less than 30% as it increases risk of polymorphic VT.</span>
::❑ 1 mg over 10 minutes (if ≥ 60 kg)
::❑ 1 mg over 10 minutes (if ≥ 60 kg)
::❑ 0.01 mg/kg over 10 minutes (if <60 kg)
::❑ 0.01 mg/kg over 10 minutes (if <60 kg)
Line 233: Line 268:
{{familytree/end}}
{{familytree/end}}


[[Adenosine]] should be used cautiously in patients with severe coronary artery disease and may produce AF.<br>
===Treatment of Specific Supraventricular Arrhythmia===
[[Ibutilide]] is especially indicated for patients with atrial flutter but should not be used in patients with [[ejection fraction]] less than 30% as it increases risk of polymorphic VT.<br>
====Focal Atrial Tachycardia====
<br>
{| style="background: #FFFFFF;"
{| style="cellpadding=0; cellspacing= 0; width: 800px;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center colspan="2"| {{fontcolor|#FFF|Management of focal atrial tachycardia}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center colspan="2" | '''''Acute treatment'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left | '''''Conversion in hemodynamically unstable patient'''''|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left|▸ '''''[[DC cardioversion]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])
|-
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left | '''''Conversion in hemodynamically stable patient'''''|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Adenosine]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR> ▸ '''''[[Verapamil]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Diltiazem]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Beta blocker]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Amiodarone]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Sotalol]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Procainamide]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Flecainide]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Propafenone]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])
|-
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left | '''''Rate control'''''|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Verapamil]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Diltiazem]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Beta blocker]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Digoxin]]''''' ([[ACC AHA guidelines classification scheme|Class IIb, level of evidence C]])
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center colspan="2" | '''''Prophylactic therapy'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left| '''''Recurrent symptomatic [[atrial tachycardia]]'''''|| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Catheter ablation]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])<BR>''OR''<BR> ▸ '''''[[Beta blockers]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Diltiazem]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Verapamil]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Disopyramide]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Amiodarone]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Sotalol]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Flecainide]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Propafenone]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])
|-
| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left| '''''Asymptomatic or symptomatic incessent [[atrial tachycardia]]'''''|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left |▸ '''''[[Catheter ablation]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])
|-
|style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left| '''''Asymptomatic and non-sustained [[atrial tachycardia]]'''''|| style="padding: 0 5px; font-size: 90%; background: #DCDCDC;" align=left |▸ '''''No therapy''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<BR>''OR''<BR>
▸ '''''[[Catheter ablation]] ''''' ([[ACC AHA guidelines classification scheme|Class III, level of evidence C]])
|-
|}
|}
 
====Focal and Nonparoxysmal Junctional Tachycardia====
 
{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center colspan="2"| {{fontcolor|#FFF|Management of focal and nonparoxysmal junctional tachycardia}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center colspan="2" | '''''[[Focal junctional tachycardia]]'''''
|-
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Beta blockers]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Amiodarone]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Sotalol]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Flecainide]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Propafenone]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Catheter ablation]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center colspan="2" | '''''Non paroxysmal junctional tachycardia'''''
|-
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''Reverse [[digitalis toxicity]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<BR>''AND''<BR>▸ '''''Correct [[hypokalemia]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<BR>''AND''<BR>▸ '''''Treat [[myocardial ischemia]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Beta blockers]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Calcium channel blockers]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])
|}
|}
 
====AVNRT====
 
{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center colspan="2"| {{fontcolor|#FFF|Management of recurrent AVNRT}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center colspan="2" | '''''[[AVNRT]] with hemodynamic intolerance'''''
|-
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Catheter ablation]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])<BR>''OR''<BR>▸ '''''[[Verapamil]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Diltiazem]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Beta blockers]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Amiodarone]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Sotalol]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Flecainide]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Propafenone]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])
|-
|style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center colspan="2" | '''''Recurrent symptomatic [[AVNRT]]'''''
|-
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Catheter ablation]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])<BR>''OR''<BR>▸ '''''[[Verapamil]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])<BR>''OR''<BR>▸ '''''[[Diltiazem]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Beta blockers]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Digoxin]]''''' ([[ACC AHA guidelines classification scheme|Class IIb, level of evidence C]])
|-
|style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center colspan="2" | '''''Recurrent [[AVNRT]] unresponsive to [[beta blockers]] and [[calcium channel blockers]],<br> patient not desiring [[radiofrequency ablation]]'' '''
|-
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''[[Flecainide]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence B]])<BR>''OR''<BR>▸ '''''[[Propafenone]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence B]])<BR>''OR''<BR>▸ '''''[[Sotalol]]''''' ([[ACC AHA guidelines classification scheme|Class IIa, level of evidence B]])<BR>''OR''<BR> ▸ '''''[[Amiodarone]]''''' ([[ACC AHA guidelines classification scheme|Class IIb, level of evidence C]])
|-
|style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center colspan="2" | '''''Single episode of [[AVNRT]] or infrequent [[AVNRT]]<br> in patients desiring complete control of arrhythmia'' '''
|-
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''[[Catheter ablation]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])
|-
 
|style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center colspan="2" | '''''Documented [[PSVT]] with only dual AV nodal pathways OR<br> single echo beats documented during electrophysiological study AND<br> no other cause of arrhythmia identified'' '''
|-
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''[[Verapamil]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Diltiazem]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Beta blockers]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Flecainide]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Propafenone]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Catheter ablation]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])
|-
|style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center colspan="2" | '''''Infrequent, well tolerated [[AVNRT]]'' '''
|-
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''No therapy''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Vagal maneuvers]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])<BR>''OR''<BR>▸ '''''Pill in the pocket''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])<BR>''OR''<BR>▸ '''''[[Verapamil]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])<BR>''OR''<BR>▸ '''''[[Diltiazem]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])<BR>''OR''<BR>▸ '''''[[Beta blockers]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])<BR>''OR''<BR>▸ '''''[[Catheter ablation]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])
|-
|}
|}
 
====Inappropriate Sinus Tachycardia====
 
{| style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 600px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center colspan="2"| {{fontcolor|#FFF|Management of inappropriate sinus tachycardia}}
|-
|style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left |▸ '''''[[Beta blockers]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Verapamil]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Diltiazem]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence C]])<BR>''OR''<BR>▸ '''''[[Catheter ablation]]''''' ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])
|-
|-
| style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Type of [[Arrhythmia]]'''||style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''[[EKG]]''' (lead II)† ||style="padding: 0 5px; font-size: 100%; background: #F5F5F5;" align=center | '''Clues'''
|-
|'''[[Supraventricular tachycardia]]'''||[[Image:SVT.png|300px|link=Narrow complex tachycardia resident survival guide]]||Any [[tachyarrhythmia]] that is initiated and maintained in atrial tissue or atrioventricular junctional tissue.<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher =  | date =  | accessdate = 15 August 2013 }}</ref>
|-
| '''[[Sinus tachycardia]]'''||[[Image:Sinus tachycardia.png|300px|link=Narrow complex tachycardia resident survival guide]]||Rhythm with heart rate  > 100 bpm, originating in [[SA node]] due to its increased automaticity.
|-
| '''[[SANRT|Sinus node re-entry tachycardia]]'''|| ||Rare paroxysmal tachycardia arising due to re-entry circuits with in [[SA node]].<ref name="Cossú-">{{Cite journal  | last1 = Cossú | first1 = SF. | last2 = Steinberg | first2 = JS. | title = Supraventricular tachyarrhythmias involving the sinus node: clinical and electrophysiologic characteristics. | journal = Prog Cardiovasc Dis | volume = 41 | issue = 1 | pages = 51-63| month =  | year =  | doi =  | PMID = 9717859 }}</ref>
|-
|'''[[Atrial fibrillation]]'''||[[Image:atrial fibrillation.png|300px|link=Narrow complex tachycardia resident survival guide]]|| Supraventricular tachycardia with irregularly irregular rhythm and absent P waves on [[EKG]].
|-
|'''[[Atrial flutter]]'''||[[Image:atrial flutter.png|300px|link=Narrow complex tachycardia resident survival guide]]||Cardiac rhythm characterized by an atrial rate ranging from 240 to 400 beats per minute and regular continuous wave-form.<ref name="pmid19668035">{{cite journal |author=Dhar S, Lidhoo P, Koul D, Dhar S, Bakhshi M, Deger FT |title=Current concepts and management strategies in atrial flutter |journal=South. Med. J. |volume=102 |issue=9 |pages=917–22 |year=2009 |month=September |pmid=19668035 |doi=10.1097/SMJ.0b013e3181b0f4b8 |url=}}</ref>
|-
| '''[[AVNRT]]'''||[[Image:AVNRT.png|300px|link=Narrow complex tachycardia resident survival guide]]||Most common form of [[PSVT]] with a heart rate of 140-250 bpm, re-entrant circuit involves two separate anatomical pathways (slow and fast) loacted in perinodal tissue.
|-
| '''[[AVRT]]'''||[[Image:AVRT.png|300px|link=Narrow complex tachycardia resident survival guide]]|| Re-entrant tachycardia occurring due to an accessory pathway in addition to [[AV node]], accessory pathway is essential for the initiation and the maintenance of tachycardia.
|-
| '''[[Focal atrial tachycardia]]'''||[[Image:focal atrial tachycardia.png|300px|link=Narrow complex tachycardia resident survival guide]]||Focal atria tachycardia refers to a rhythm originating from a single site either in the left or right atrium with an atrial rate of 100-250 bpm.
|-
|'''Nonparoxysmal junctional tachycardia'''||[[Image:JTS.png|300px|link=Narrow complex tachycardia resident survival guide]]||Benign tachycardia occurring due to increased automaticity arising from a high junctional focus.
|-
| '''[[Multifocal atrial tachycardia]]'''||[[Image:MAT.png|300px|link=Narrow complex tachycardia resident survival guide]]|| Irregular tachycardia characterized by 3 different P wave morphologies on [[EKG]].
|-
|}
|}
† [[EKG]] strips are a courtesy from ECGpedia.
|}
<br>


==Do's==
==Do's==
* Consider the arrhythmia to be paroxysmal if it is recurrent and abruptly begins and terminates.
*Identify possible triggers and educate the patient to avoid them.
* Refer patients with narrow complex tachycardia with any of the following to a cardiac arrhythmia specialist:
* Refer patients with narrow complex tachycardia with any of the following to a cardiac arrhythmia specialist:
:* Drug resistance
:* Drug resistance
Line 274: Line 373:
* Consider trying different types of anti-arrhythmic agents in case the [[SVT]] is refractory; however, closely monitor the [[blood pressure]] and [[heart rate]].<ref name="pmid16525141">{{cite journal| author=Delacrétaz E| title=Clinical practice. Supraventricular tachycardia. | journal=N Engl J Med | year= 2006 | volume= 354 | issue= 10 | pages= 1039-51 | pmid=16525141 | doi=10.1056/NEJMcp051145 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16525141  }} </ref>
* Consider trying different types of anti-arrhythmic agents in case the [[SVT]] is refractory; however, closely monitor the [[blood pressure]] and [[heart rate]].<ref name="pmid16525141">{{cite journal| author=Delacrétaz E| title=Clinical practice. Supraventricular tachycardia. | journal=N Engl J Med | year= 2006 | volume= 354 | issue= 10 | pages= 1039-51 | pmid=16525141 | doi=10.1056/NEJMcp051145 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16525141  }} </ref>


* Consider invasive electrophysiological investigation in presence of pre-excitation and severe disabling symptoms.
* Consider invasive electrophysiological investigation in the presence of pre-excitation and severe disabling symptoms.


* Monitor the [[12 lead ECG]] during the administration of[[ adenosine]] or carotid massage.
* Monitor the [[12 lead ECG]] during the administration of[[ adenosine]] or carotid massage.
Line 280: Line 379:
* Make sure the equipment for resuscitation is available during the administration of [[adenosine]] in case of the occurrence of any complication, such as [[ventricular fibrillation]] or [[bronchospasm]].<ref name="pmid16525141">{{cite journal| author=Delacrétaz E| title=Clinical practice. Supraventricular tachycardia. | journal=N Engl J Med | year= 2006 | volume= 354 | issue= 10 | pages= 1039-51 | pmid=16525141 | doi=10.1056/NEJMcp051145 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16525141  }} </ref>
* Make sure the equipment for resuscitation is available during the administration of [[adenosine]] in case of the occurrence of any complication, such as [[ventricular fibrillation]] or [[bronchospasm]].<ref name="pmid16525141">{{cite journal| author=Delacrétaz E| title=Clinical practice. Supraventricular tachycardia. | journal=N Engl J Med | year= 2006 | volume= 354 | issue= 10 | pages= 1039-51 | pmid=16525141 | doi=10.1056/NEJMcp051145 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16525141  }} </ref>


* Consider esophageal pill electrodes in cases of invisible P waves.
* Administer higher doses of [[adenosine]] in patients taking [[theophylline]].
* Administer higher doses of [[adenosine]] in patients taking [[theophylline]].
* Perform the following tests when indicated:
* Perform the following tests when indicated:
:*[[Echocardiography]] in case of sustained [[SVT]] to rule out structural heart disease
:*[[Echocardiography]] in case of sustained [[SVT]] to rule out structural heart disease
:*24 hour [[holter monitor]] in case of frequent but transient tachycardia
:*24 hour [[holter monitor]] in case of frequent but transient tachycardia
:*Loop recorder in patients with less frequent arrhythmias
:*Loop recorder in patients with less frequent arrhythmia
:*Trans-esophageal atrial recordings if other investigations have failed to document an [[arrhythmia]]
:*Trans-esophageal atrial recordings if other investigations have failed to document an [[arrhythmia]]



Latest revision as of 15:47, 30 April 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hilda Mahmoudi M.D., M.P.H.[2]; Twinkle Singh, M.B.B.S. [3]; Rim Halaby, M.D. [4]; Amr Marawan, M.D. [5]

Narrow Complex Tachycardia Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Initial
Specific
Do's
Don'ts

Overview

Narrow complex tachycardia is characterized by a heart rate > 100 beats per minute and a QRS complex of a duration < 120 milliseconds. Narrow complex tachycardia may originate in the sinus node, atria, AV node, bundle of His, or a combination of these tissues. The diagnosis of narrow complex tachycardia is based on the ECG findings. Hemodynamically unstable patients should receive urgent synchronized cardioversion.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Boxes in the red color signify that an urgent management is needed.

 
 
 
 
 
 
Identify cardinal findings that increase the pretest probability of narrow complex tachycardia
Palpitations
Heart rate > 100 beats/min
QRS complex < 120 ms

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the following findings that require urgent cardioversion?

❑ Hemodynamic instability

Hypotension
Cold extremities
Peripheral cyanosis
Mottling
Altered mental status

Chest discomfort suggestive of ischemia

Decompensated heart failure[1]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Urgent synchronized cardioversion
❑ Narrow regular rhythm: 50-100 Joules
❑ Narrow irregular rhythm: 120-200 Joules biphasic or 200 Joules monophasic[1][2]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[2]
Abbreviations: ECG: electrocardiogram; SVT: Supraventricular tachycardia; ms: milliseconds; AV: atrioventricular; AVNRT: atrioventricular nodal reciprocating tachycardia; MAT: multifocal atrial tachycardia; ms: milliseconds; PJRT: permanent form of junctional reciprocating tachycardia; RP interval: is the time between anterograde ventricular activation (R wave) and retrograde atrial activation (P wave)

 
 
 
 
 
 
 
Characterize the symptoms:

❑ Asymptomatic (most common presentation)
Palpitations
❑ Sensation of a pause followed by a strong heart beat (suggestive of premature beats)
Dyspnea
Fatigue
Chest discomfort
Lightheadedness
Syncope
Polyuria
Characterize the timing of the symptoms:
❑ Onset

❑ First episode
❑ Recurrent

❑ Duration
❑ Frequency
❑ Termination of the episode

❑ Spontaneous
❑ Medication use
❑ Not terminated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Examine the patient:
Vitals
Pulse

❑ Rate
Tachycardia
❑ Rhythm
❑ Regular
❑ Irregular (atrial fibrillation, MAT)
❑ Strength
❑ Weak
❑ Alternating in strength (atrial fibrillation)

Respiration

Tachypnea

Blood pressure

Normal (typical)
Hypotension (in hemodynamically unstable patients)

Neck

❑ Absent a wave in jugular venous pressure (in atrial fibrillation)

Cardiovascular examination
❑ Auscultation

Heart sounds
❑ Rapid regular or irregular beats
❑ Murmurs (suggestive of valvular diseases)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ Order and monitor the ECG
Perform urgent cardioversion in unstable patients

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Narrow QRS tachycardia
Heart rate > 100 beats/min
QRS complex < 120 ms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Determine the regularity of the rhythm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Regular rhythm
 
 
 
 
 
 
 
Irregular rhythm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider the following causes:

AVRT
AVNRT
Atypical AVNRT
Atrial tachycardia

Atrial flutter
 
 
 
 
 
 
 
Consider the following causes:

Atrial fibrillation
Atrial tachycardia/flutter with variable AV conduction

MAT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine P wave morphology
 
 
 
 
 
 
 
Determine P wave morphology
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
P waves are not visible
 
P waves are visible
 
❑ > 3 P wave morphologies
 
❑ Absent P waves
 
❑ Sawtooth appearance of P waves
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Consider AVNRT
 
Determine if atrial rate is greater than ventricular rate
 
❑ Consider MAT
 
❑ Consider atrial fibrillation
 
❑ Consider atrial flutter
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Atrial rate > ventricular rate
 
Atrial rate ≤ ventricular rate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider the following causes:
Atrial flutter
Atrial tachycardia
 
❑ Determine if RP interval > PR interval
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
RP < PR
 
 
 
RP > PR
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine the duration of RP interval
 
 
 
Consider the following causes:

Atrial tachycardia
❑ PJRT

Atypical AVNRT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
< 70 ms
 
> 70 ms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider the following cause:
AVNRT
 
Consider the following causes:
AVRT
AVNRT
Atrial tachycardia
 
 
 
 
 
 
 
 
 


ECG Examples

Shown below is a table depicting the ECG findings of the different types of narrow complex tachycardia.[3][4]

Type of Arrhythmia EKG (lead II)† Clues
Sinus tachycardia Onset and termination: gradual
Rhythm: regular
Rate: >220 minus the age of the patient
Response to adenosine: transient decrease of the rate
Atrial fibrillation Onset and termination: abrupt
Rhythm: irregular
Rate:100-180 bpm
Response to adenosine: transient decrease of the ventricular rate
Atrial flutter Onset and termination: abrupt
Rhythm: regular
Rate: >150 bpm
Response to adenosine: transient decrease of the rate
Presence of saw-tooth appearance
AVNRT Onset and termination: abrupt
Rhythm: regular
Rate: 150-250 bpm
Response to adenosine: termination of the arrhythmia
AVRT Onset and termination: abrupt
Rhythm: regular
Rate: 150-250 bpm
Response to adenosine: termination of the arrhythmia
Focal atrial tachycardia Onset and termination: abrupt
Rhythm: regular
Rate: 150-250 bpm
Nonparoxysmal junctional tachycardia Rhythm: regular
Retrograde P wave
Most commonly due to ischemia or digitalis toxicity
Multifocal atrial tachycardia Onset and termination: gradual
Rhythm: irregular
Rate: 100-150 bpm
Response to adenosine: no effect
3 different P wave morphologies

ECG strips are courtesy of ECGpedia.

Treatment

Initial Treatment

Shown below is an algorithm summarizing the management of narrow complex tachycardia according to the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias.[2]
Abbreviations: AF: atrial fibrillation; AV: atrioventricular; AVNRT: atrioventricular nodal reciprocating tachycardia; AVRT: atrioventricular reciprocating tachycardia; BBB: bundle-branch block; ECG: electrocardiography; IV: intravenous; LV: left ventricle; SVT: supraventricular tachycardia; VT: ventricular tachycardia

 
 
Does the patient have any of the following findings that require urgent cardioversion?

❑ Hemodynamic instability

Hypotension
Cold extremities
Peripheral cyanosis
Mottling
Altered mental status

Chest discomfort suggestive of ischemia

Decompensated heart failure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
Urgent synchronized cardioversion

❑ Narrow regular rhythm: 50-100 J

❑ Narrow irregular rhythm: 120-200 J biphasic or 200 J monophasic
 
Acute management:

❑ Perform vagal maneuvers (Class I, level of evidence B)

Valsalva maneuver
Carotid sinus massage

Carotid massage is contraindicated in case of prior MI, transient ischemic attack or stroke within the last three months, previous history of ventricular fibrillation or fibrillation tachycardia, and in case of carotid bruits.[5]

❑ Monitor ECG continuously
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If vagal maneuvers fail:

❑ Administer IV adenosine (Class I, level of evidence A)

❑ First dose: 6 mg rapid IV push, followed by 20 mL of normal saline bolus
❑ Second dose: 12 mg (if no response in 1-2 min)

Adenosine is contraindicated in cardiac transplant patients. Use adenosine with caution in severe obstructive lung disease.[3]

❑ Monitor ECG continuously
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If adenosine fails, administer ONE of the following:

❑ IV verapamil 5 mg IV every 3-5 min, maximum 15 mg (Class I, level of evidence A)[3]
❑ IV diltiazem (Class I, level of evidence A)

❑ 0.25 mg/kg over 2 minutes
❑ Additional 0.35 mg/kg over 2 minutes
❑ Maintenance infusion of 5-15 mg/hour[3]

❑ IV beta blocker (Class IIb, level of evidence C)

Metoprolol
❑ 5 mg over 2 minutes
❑ Up to 3 doses within 15 minutes
Esmolol
❑ 250-500 μg/kg over 1 minute
❑ Maintenance with 50-200 μg/kg over 4 minutes (if needed)
Propranolol
❑ 0.15 mg/kg over 2 minutes[3]

❑ Monitor ECG continuously
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Arrhythmia is terminated
 
Arrhythmia is persistent
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No further therapy is required if:
❑ Patient is stable
LV function is normal
❑ Normal sinus rhythm on ECG
 
❑ Administer AV-nodal-blocking agent AND one of the following
❑ IV ibutilide

Ibutilide is especially indicated for patients with atrial flutter but should not be used in patients with ejection fraction less than 30% as it increases risk of polymorphic VT.

❑ 1 mg over 10 minutes (if ≥ 60 kg)
❑ 0.01 mg/kg over 10 minutes (if <60 kg)
❑ Repeat once after 10 minutes if needed
❑ IV procainamide
❑ 30 mg/min infusion, maximum 17 mg/kg
❑ Maintenance 2-4 mg/min
❑ IV flecainide 2mg/kg over 10 min[3]

OR

❑ DC cardioversion
 

Treatment of Specific Supraventricular Arrhythmia

Focal Atrial Tachycardia

Management of focal atrial tachycardia
Acute treatment
Conversion in hemodynamically unstable patient DC cardioversion (Class I, level of evidence B)
Conversion in hemodynamically stable patient Adenosine (Class IIa, level of evidence C)
OR
Verapamil (Class IIa, level of evidence C)
OR
Diltiazem (Class IIa, level of evidence C)
OR
Beta blocker (Class IIa, level of evidence C)
OR
Amiodarone (Class IIa, level of evidence C)
OR
Sotalol (Class IIa, level of evidence C)
OR
Procainamide (Class IIa, level of evidence C)
OR
Flecainide (Class IIa, level of evidence C)
OR
Propafenone (Class IIa, level of evidence C)
Rate control Verapamil (Class I, level of evidence C)
OR
Diltiazem (Class I, level of evidence C)
OR
Beta blocker (Class I, level of evidence C)
OR
Digoxin (Class IIb, level of evidence C)
Prophylactic therapy
Recurrent symptomatic atrial tachycardia Catheter ablation (Class I, level of evidence B)
OR
Beta blockers (Class I, level of evidence C)
OR
Diltiazem (Class I, level of evidence C)
OR
Verapamil (Class I, level of evidence C)
OR
Disopyramide (Class IIa, level of evidence C)
OR
Amiodarone (Class IIa, level of evidence C)
OR
Sotalol (Class IIa, level of evidence C)
OR
Flecainide (Class IIa, level of evidence C)
OR
Propafenone (Class IIa, level of evidence C)
Asymptomatic or symptomatic incessent atrial tachycardia Catheter ablation (Class I, level of evidence B)
Asymptomatic and non-sustained atrial tachycardia No therapy (Class I, level of evidence C)
OR

Catheter ablation (Class III, level of evidence C)

Focal and Nonparoxysmal Junctional Tachycardia

Management of focal and nonparoxysmal junctional tachycardia
Focal junctional tachycardia
Beta blockers (Class IIa, level of evidence C)
OR
Amiodarone (Class IIa, level of evidence C)
OR
Sotalol (Class IIa, level of evidence C)
OR
Flecainide (Class IIa, level of evidence C)
OR
Propafenone (Class IIa, level of evidence C)
OR
Catheter ablation (Class IIa, level of evidence C)
Non paroxysmal junctional tachycardia
Reverse digitalis toxicity (Class I, level of evidence C)
AND
Correct hypokalemia (Class I, level of evidence C)
AND
Treat myocardial ischemia (Class I, level of evidence C)
OR
Beta blockers (Class IIa, level of evidence C)
OR
Calcium channel blockers (Class IIa, level of evidence C)

AVNRT

Management of recurrent AVNRT
AVNRT with hemodynamic intolerance
Catheter ablation (Class I, level of evidence B)
OR
Verapamil (Class IIa, level of evidence C)
OR
Diltiazem (Class IIa, level of evidence C)
OR
Beta blockers (Class IIa, level of evidence C)
OR
Amiodarone (Class IIa, level of evidence C)
OR
Sotalol (Class IIa, level of evidence C)
OR
Flecainide (Class IIa, level of evidence C)
OR
Propafenone (Class IIa, level of evidence C)
Recurrent symptomatic AVNRT
Catheter ablation (Class I, level of evidence B)
OR
Verapamil (Class I, level of evidence B)
OR
Diltiazem (Class I, level of evidence C)
OR
Beta blockers (Class IIa, level of evidence C)
OR
Digoxin (Class IIb, level of evidence C)
Recurrent AVNRT unresponsive to beta blockers and calcium channel blockers,
patient not desiring radiofrequency ablation
Flecainide (Class IIa, level of evidence B)
OR
Propafenone (Class IIa, level of evidence B)
OR
Sotalol (Class IIa, level of evidence B)
OR
Amiodarone (Class IIb, level of evidence C)
Single episode of AVNRT or infrequent AVNRT
in patients desiring complete control of arrhythmia
Catheter ablation (Class I, level of evidence B)
Documented PSVT with only dual AV nodal pathways OR
single echo beats documented during electrophysiological study AND
no other cause of arrhythmia identified
Verapamil (Class I, level of evidence C)
OR
Diltiazem (Class I, level of evidence C)
OR
Beta blockers (Class I, level of evidence C)
OR
Flecainide (Class I, level of evidence C)
OR
Propafenone (Class I, level of evidence C)
OR
Catheter ablation (Class I, level of evidence B)
Infrequent, well tolerated AVNRT
No therapy (Class I, level of evidence C)
OR
Vagal maneuvers (Class I, level of evidence B)
OR
Pill in the pocket (Class I, level of evidence B)
OR
Verapamil (Class I, level of evidence B)
OR
Diltiazem (Class I, level of evidence B)
OR
Beta blockers (Class I, level of evidence B)
OR
Catheter ablation (Class I, level of evidence B)

Inappropriate Sinus Tachycardia

Management of inappropriate sinus tachycardia
Beta blockers (Class I, level of evidence C)
OR
Verapamil (Class I, level of evidence C)
OR
Diltiazem (Class I, level of evidence C)
OR
Catheter ablation (Class I, level of evidence B)

Do's

  • Consider the arrhythmia to be paroxysmal if it is recurrent and abruptly begins and terminates.
  • Identify possible triggers and educate the patient to avoid them.
  • Refer patients with narrow complex tachycardia with any of the following to a cardiac arrhythmia specialist:
  • Consider trying different types of anti-arrhythmic agents in case the SVT is refractory; however, closely monitor the blood pressure and heart rate.[3]
  • Consider invasive electrophysiological investigation in the presence of pre-excitation and severe disabling symptoms.
  • Administer higher doses of adenosine in patients taking theophylline.
  • Perform the following tests when indicated:
  • Echocardiography in case of sustained SVT to rule out structural heart disease
  • 24 hour holter monitor in case of frequent but transient tachycardia
  • Loop recorder in patients with less frequent arrhythmia
  • Trans-esophageal atrial recordings if other investigations have failed to document an arrhythmia

Don'ts

  • Do not perform esophageal stimulation if an invasive electrophysiological investigation is planned.
  • Do not initiate treatment with anti-arrhythmic agents in a patient with undocumented arrhythmia.
  • Do not administer adenosine in patients with severe bronchial asthma or heart transplant recipients.[3]

References

  1. 1.0 1.1 "Part 8: Adult Advanced Cardiovascular Life Support". Retrieved 3 April 2014.
  2. 2.0 2.1 2.2 "ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary". Retrieved 15 August 2013.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 Delacrétaz E (2006). "Clinical practice. Supraventricular tachycardia". N Engl J Med. 354 (10): 1039–51. doi:10.1056/NEJMcp051145. PMID 16525141.
  4. Link MS (2012). "Clinical practice. Evaluation and initial treatment of supraventricular tachycardia". N Engl J Med. 367 (15): 1438–48. doi:10.1056/NEJMcp1111259. PMID 23050527.
  5. "Tips From Other Journals - American Family Physician". Retrieved 3 April 2014.


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