Narrow complex tachycardia resident survival guide: Difference between revisions
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{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=PE diagnosis Algorithm.}} | ||
{{familytree | | | | | | | | A01 | | | | | | | |A01= Charcterize the symptoms}} | |||
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{{familytree | | | | | | | | B01 | | | | | | | |B01= Examine the patient}} | |||
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{{familytree | | | | | | | | C01 | | | | | | | |C01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">Order tests<br> | |||
❑ [[ECG]]<br>❑ [[Echocardiography]] (in patients with sustained [[SVT]])†</div>}} | |||
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{{familytree | | | | | | | | A01 |A01=Narrow QRS tachycardia<br>(QRS duration less than 120 ms)}} | {{familytree | | | | | | | | A01 |A01=Narrow QRS tachycardia<br>(QRS duration less than 120 ms)}} | ||
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{{familytree |L|~| K01 | | K02 | | | | | | | | | | K01=[[AVNRT]]|K02=[[AVRT]]<br>[[AVNRT]]<br>Atrial tachycardia}} | {{familytree |L|~| K01 | | K02 | | | | | | | | | | K01=[[AVNRT]]|K02=[[AVRT]]<br>[[AVNRT]]<br>Atrial tachycardia}} | ||
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† Echocardiographic examination is required in patients with documented sustained [[supraventricular tachycardia]] to rule out structural heart disease. | |||
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>AV indicates atrioventricular; [[AVNRT]], [[atrioventricular nodal reciprocating tachycardia]]; [[MAT]], [[multifocal atrial tachycardia]]; ms, miliseconds; PJRT, permanent form of junctional reciprocating tachycardia; QRS, ventricular activation on ECG.<br> | 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>AV indicates atrioventricular; [[AVNRT]], [[atrioventricular nodal reciprocating tachycardia]]; [[MAT]], [[multifocal atrial tachycardia]]; ms, miliseconds; PJRT, permanent form of junctional reciprocating tachycardia; QRS, ventricular activation on ECG.<br> | ||
''Algorithm based on the 2003 ACC/AHA/ESC guidelines for the management of 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> | ''Algorithm based on the 2003 ACC/AHA/ESC guidelines for the management of 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> | ||
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:*: Patients with intolerance to drugs | :*: Patients with intolerance to drugs | ||
:*: Patients who do not want any drug therapy. | :*: Patients who do not want any drug therapy. | ||
*:* Patients with severe symptoms such as [[syncope]] and [[dyspnoea]] during [[palpitations]]. | |||
* Refer all the patients with [[Wolff-Parkinson-White syndrome]] (WPW syndrome) to a cardiac arrhythmia specialist. | |||
* | |||
==Don'ts== | ==Don'ts== | ||
Revision as of 19:01, 2 March 2014
| File:Critical Pathways.gif |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hilda Mahmoudi M.D., M.P.H.[2]
Definition
Narrow complex tachycardia is defined as a rhythm with heart rate > 100 beats per minute and a QRS complex duration < 120 milliseconds.
Causes
Life Threatening Causes
Life-threatening causes include conditions which result in death or permanent disability within 24 hours if left untreated.
Common Causes
Management
Figure 1: Differential diagnosis for narrow QRS tachycardia.[1]
| Charcterize the symptoms | |||||||||||||||||||||||||||||||||||||||||||
| Examine the patient | |||||||||||||||||||||||||||||||||||||||||||
| Narrow QRS tachycardia (QRS duration less than 120 ms) | |||||||||||||||||||||||||||||||||||||||||||
| Regular tachycardia? | |||||||||||||||||||||||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||||||||||||||||||||||
| Visible P waves? | Atrial fibrillation Atrial tachycardia/flutter with variable AV conduction MAT | ||||||||||||||||||||||||||||||||||||||||||
| No | Yes | ||||||||||||||||||||||||||||||||||||||||||
| Atrial rate greater than ventricular rate? | |||||||||||||||||||||||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||||||||||||||||||||||
| Atrial flutter or atrial tachycardia | Analyze RP interval | ||||||||||||||||||||||||||||||||||||||||||
| Short (RP shorter than PR) | Long (RP longer than PR) | ||||||||||||||||||||||||||||||||||||||||||
| RP shorter than 70 ms | RP longer than 70 ms | Atrial tachycardia PJRT Atypical AVNRT | |||||||||||||||||||||||||||||||||||||||||
| AVNRT | AVRT AVNRT Atrial tachycardia | ||||||||||||||||||||||||||||||||||||||||||
† Echocardiographic examination is required in patients with documented sustained supraventricular tachycardia to rule out structural heart disease.
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.
AV indicates atrioventricular; AVNRT, atrioventricular nodal reciprocating tachycardia; MAT, multifocal atrial tachycardia; ms, miliseconds; PJRT, permanent form of junctional reciprocating tachycardia; QRS, ventricular activation on ECG.
Algorithm based on the 2003 ACC/AHA/ESC guidelines for the management of supraventricular arrhythmias.[1]
Figure 2: Acute management of patients with hemodynamically stable and narrow QRS regular tachycadia:[1]
| Hemodynamically stable regular tachycardia | |||||||||||||||||||||||||||||||||||||||||||
| Narrow QRS | |||||||||||||||||||||||||||||||||||||||||||
| SVT | |||||||||||||||||||||||||||||||||||||||||||
| Vagal maneuvers IV adenosine† IV verapamil/diltiazem IV beta blocker | |||||||||||||||||||||||||||||||||||||||||||
| Termination | |||||||||||||||||||||||||||||||||||||||||||
| Yes | No,persistent tachycardia with AV block | ||||||||||||||||||||||||||||||||||||||||||
| *IV ibutilide plus AV-nodal-blocking agent Overdrive pacing/DC cardioversion, and/or rate control | |||||||||||||||||||||||||||||||||||||||||||
†Adenosine should be used with caution in patients with severe coronary artery disease and may produce
AF, which may result in rapid ventricular rates for patients with pre-excitation. *Ibutilide is especially effective for patients with atrial flutter but should not be used in patients with EF less than 30% due to increased risk of polymorphic VT. AF indicates atrial fibrillation; AV, atrioventricular; BBB, bundle-branch block; DC, direct current; IV, intravenous; LV, left ventricle; QRS, ventricular activation on ECG; SVT, supraventricular tachycardia; VT, ventricular tachycardia.
Algorithm based on the 2003 ACC/AHA/ESC guidelines for the management of supraventricular arrhythmias.[1]
Figure 3: Responses of narrow complex tachycardias to adenosine.[1]
| Regular narrow QRS complex tachycardia | |||||||||||||||||||||||||||||||||||||||||||||||
| IV adenosine | |||||||||||||||||||||||||||||||||||||||||||||||
| No change in rate | Gradual slowing then reacceleration of rate | Sudden termination | Persisting atrial tachycardia with transient high-grade AV block | ||||||||||||||||||||||||||||||||||||||||||||
| Inadequate dose/delivery Condiser VT (fascicular or hight septal origin) | Sinus tachycardia Focal AT Nonparoxysmal junctional tachycardia | AVNRT AVRT Sinus node re-entry Focal AT | Atrial flutter AT | ||||||||||||||||||||||||||||||||||||||||||||
AT indicates atrial tachycardia; AV, atrioventricular; AVNRT, atrioventricular nodal reciprocating tachycardia; AVRT, atrioventricular reciprocating tachycardia; IV, intravenous; QRS, ventricular activation on ECG; VT, ventricular tachycardia.
Algorithm based on the 2003 ACC/AHA/ESC guidelines for the management of supraventricular arrhythmias.[1]
Do's
- Refer narrow complex tachycardic patients with following characteristics to a cardiac arrhythmia specialist:
- Patients with drug resistance
- Patients with intolerance to drugs
- Patients who do not want any drug therapy.
- Patients with severe symptoms such as syncope and dyspnoea during palpitations.
- Refer all the patients with Wolff-Parkinson-White syndrome (WPW syndrome) to a cardiac arrhythmia specialist.