This document discusses narrow complex tachycardia, defining it as a heart rate over 100 bpm with a QRS duration under 120 ms. It describes various types of tachycardia including sinus tachycardia, supraventricular tachycardia, atrial fibrillation, atrial flutter, atrial tachycardia, multifocal atrial tachycardia, and junctional tachycardia. It provides details on management of supraventricular tachycardia including vagal maneuvers, adenosine, verapamil, beta blockers, and cardioversion. Other conditions discussed include Wolff-Parkinson-White syndrome, Long Ganong Levine syndrome, and Holiday heart syndrome

1. Narrow complex tachycardia
Domina Petric, MD

2. Definition
• Heart rate >100 bpm!
• QRS duration <120 ms!
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3. Types of tachycardia
Sinus tachycardia: normal P wave
followed by normal QRS.
Supraventricular tachycardia
(SVT): P wave absent or inverted
after QRS.

4. Types of tachycardia
• Atrial fibrillation: absent P wave,
irregular QRS complexes.
• Atrial flutter: atrial rate usually 300 bpm
with flutter waves (sawtooth), ventricular
rate 150 bpm (2:1 block).
• Atrial tachycardia: abnormally shaped P
waves, may outnumber QRS complexes.

5. Types of tachycardia
• Multifocal atrial tachycardia: three
or more P wave morphologies,
irregular QRS complexes.
• Junctional tachycardia: rate 150-
250 bpm, P wave eaither buried in
QRS complex or occurring after
QRS complex.

6. Management of SVT
Vagal manoeuvres:
• breath holding
• valsalva manoeuvre
• carotid massage

7. Management of SVT
Vagal manoeuvres can be
used only if the patient is
haemodynamically
stable.

8. Management of SVT
Adenosine iv. is next step:
• 6 mg iv. bolus into a big vein
• saline flush
• recording a rhythm strip
• after 1-2 min, 12 mg iv. if necessary

9. Adenosine
• Side effects are transient chest tightness,
dyspnoea, headache and flushing.
• Contraindications: asthma AV block of
second and third degree, sinoatrial
disease (without pacemaker).
• Important drug interactions:
dipyridamole increase levels,
theophylline antagonises adenosine.

10. Management of SVT
• If adenosine is not effective, verapamil
can be used in dose of 5 mg iv. over 2
minutes (over 3 minutes in elderly).
• Verapamil can not be used if the patient
is taking beta blockers.
• If there is no response, dose of 5 mg iv.
can be repeated after 5-10 minutes.

11. Management of SVT
Alternatives:
• atenolol 2,5 mg iv. at 1 mg/min repeated
at 5 minutes intervals to a maximum dose
of 10 mg
• sotalol 20-60 mg iv. over 10 minutes in
patients with estimated glomerular
filtration rate more than 60
• DC cardioversion

12. Atrial tachycardia

13. Multifocal atrial tachycardia
• Most commonly occurs in COPD.
• There are at least 3 morphologically
distinct P waves with irregular P-P
intervals.
• It is very important to correct hypoxia
and hypercapnia.
• If heart rate >110 bpm, verapamil or a
BB can be used as well.

14. Image source: lifeinthefastlane.com
There are at least 3
morphologically distinct P
waves with irregular P-P
intervals.

15. Junctional tachycardia
AV nodal re-entry tachycardia (AVNRT)
AV re-entry tachycardia (AVRT)
His bundle tachycardia

16. Junctional tachycardia
• Vagal manoeuvres in cases of
anterograde conduction through
the AV node.
• Adenosine!
• Beta blockers or amiodarone!
• Radiofrequency ablation!

17. Wolff-Parkinson-White
syndrome (WPW)
• It is caused by congenital accessory
conduction pathway between atria
and ventricles.
• ECG: short PR interval, wide QRS
complex due to slurred upstroke
(delta wave) and ST-T changes.

18. Wolff-Parkinson-White
syndrome (WPW)
• WPW type A: positive delta wave in V1.
• WPW type B: negative delta wave in V1.
Delta wave

19. Wolff-Parkinson-White
syndrome (WPW)
• Patients may present with SVT.
• Tachycardia may be due to an
AVRT, pre-excited atrial
fibrillation or flutter.
• Electrophysiological testing and
ablation of accessory pathway!

20. Long Ganong Levine syndrome
It is similar to WPW
syndrome, except
there is no delta
waves!

21. Holiday heart syndrome
• Binge drinking in a person without
any clinical evidence of heart disease
may result in acute cardiac rhythm
and conduction disturbances.
• Recreational use of marijuana may
have similar effects.

22. Holiday heart syndrome

23. Stop heavy
drinking!

24. Literature
• Oxford Handbook of Clinical Medicine.
Longmore M. Wilkinson I. B. Baldwin A.
Elizabeth W. Ninth edition.
• Lifeinthefastlane.com
• Ecgcore.com