Ecg

1. Narrow complex tachycardia

2. Definition
• Heart rate >100 bpm!
• QRS duration <120 ms!
Image source: Lifeinthefastlane.com

3. Types of tachycardia
Sinus tachycardia: normal Pwave
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
AVnodal re-entry tachycardia (AVNRT)
AVre-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