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Evaluation and Initial Treatment of Supraventricular Tachycardia
This document provides information to help differentiate types of supraventricular tachycardia, including: 1. The initial differential diagnosis should focus on regularity, rate, and onset rather than atrial activity on ECG. 2. Regular types include sinus tachycardia, atrial flutter, AV nodal reentrant tachycardia, AV reciprocating tachycardia, and atrial tachycardia. Irregular types include atrial fibrillation, atrial flutter with irregular conduction, and multifocal atrial tachycardia. 3. Adenosine can help distinguish types by terminating rhythms dependent on AV node conduction like AV nodal reentrant
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Evaluation and Initial Treatment of Supraventricular Tachycardia
- 1. CLINICAL PRACTICE Evaluationand Initial Treatment of Supraventricular Tachycardia 2012;367:1438-48.
- 3. Atrial fibrillation (AF) Underlying causes Response to Adenosine Cardiac disease, pulmonary Termination of tachycardia disease, pulmonary embolism, hyperthyroidism, Atiral Activity and P:QRS postoperative Relationship Fibrillatory waves, no Regularity relationship to QRS Irregular ECG Rate (bpm) 100-220 Onset Sudden or gradual (if in chronic AF)
- 4. Multifocal atrial tachycardia (MAT) Underlying causes Response to Adenosine Pulmonary disease, None theophylline therapy Atiral Activity and Regularity P:QRS Relationship Irregular Changing P morphologic features before QRS Rate (bpm) 100-150 ECG Onset Gradual
- 5. Frequent atrial premature contractions Underlying causes Response to Adenosine Caffeine, stimulants None Regularity Atiral Activity and Irregular P:QRS Relationship P before QRS Rate (bpm) 100-150 ECG Onset Gradual
- 6. Sinus tachycardia Underlyingcauses Response to Adenosine Sepsis, hypovolemia, Transient slowing anemia, pulmonary embolism, pain, fear, fright, Atiral Activity and P:QRS exertion, myocardial Relationship ischemia, hyperthyroidism, P before QRS heart failure ECG Regularity Regular Rate (bpm) 220 minus the patient’s age Onset Gradual
- 7. Atrial flutter (AFL) Underlying causes Response to Adenosine Cardiac disease Transient slowing of ventricular rate Regularity Regular (occasionally Atiral Activity and irregular if variable AV P:QRS Relationship conduction) Flutter wave, usually 2:1 Rate (bpm) ECG 150 Onset Sudden
- 8. AV nodal reentranttachycardia (AVNRT) Underlying causes Response to Adenosine Non Termination of tachycardia Regularity Atiral Activity and Regular P:QRS Relationship Rate (bpm) No apparent atrial activity or R’ at termination of QRS 150-250 ECG Onset Sudden
- 9. AV reciprocating tachycardia (AVRT) Underlying causes Response to Adenosine Rarely, Ebstein’s anomaly Termination of tachycardia Regularity ECG Regular In narrow complex, P after QRS Rate (bpm) 150-250 In wide complex, P rarely observed Onset Sudden In irregular rhythm (Afib), no apparent P wave
- 10. Atrial tachycardia (AT) Underlying causes Response to Adenosine Cardiac disease, Termination of tachycardia pulmonary disease Atiral Activity and Regularity P:QRS Relationship Regular P before QRS Rate (bpm) ECG 150-250 Onset Sudden
- 11. Irregular RegularSupraventricularTachycardias SupraventricularTachycardias
- 12. Differential Diagnosis of SupraventricularTachycardias The initial differential diagnosis of supraventricular tachycardias should focus on the ventricular response characteristics of regularity, rate, and rapidity of onset, not on the atrial depolarization from the ECG. The regular supraventricular tachycardias include sinus tachycardia, atrial flutter, atrioventricular nodal reentrant tachycardia, atrioventricular reciprocating tachycardia, and atrial tachycardia. The irregular supraventricular tachycardias are atrial fibrillation, atrial flutter with variable atrioventricular block, and multifocal atrial tachycardia; multiple atrial premature contractions can cause a similar presentation.
- 13. Differential Diagnosis of SupraventricularTachycardias Sudden onset and termination are characteristic of acute atrial fibrillation and atrial flutter, atrioventricular nodal reentrant tachycardia, atrioventricular reciprocating tachycardia, and atrial tachycardia. Gradual onset and recession occur with sinus tachycardia, chronic atrial fibrillation and atrial flutter, multifocal atrial tachycardia, and atrial premature contractions.
- 14. Differential Diagnosis of SupraventricularTachycardias Adenosine blocks the atrioventricular node and is useful in distinguishing among supraventricular tachycardias but should not be given in the case of irregular wide-complex tachycardias, since it may render these rhythms unstable. After administration of adenosine, slowing of the heart rate is consistent with a diagnosis of sinus tachycardia, atrial tachycardia, atrial fibrillation, or atrial flutter, whereas termination of tachycardia points to atrioventricular nodal reentrant tachycardia, atrioventricular reciprocating tachycardia, and some atrial tachycardias.
- 15. Narrow-complex tachycardia Regular rhythm Irregular rhythm Sudden onset Gradual onset HR <150 bpm HR •≧150 bpm Adenosine ST AF, MAT, NSR, AF, AFL with or ST with APCs variable block Termination No termination Treat underlying cause Rate control with β- blocker, verapamil, diltiazem; AVNRT, AT, AFL (ST, if unstable condition, AVRT, AT less frequently) cardioversion, procainamide, Differential Diagnosis and Treatment ibutilde of Narrow-Complex Tachycardias.
- 16. Wide-complex tachycardia Underlying heart disease No Yes Irregular rhythm Regular rhythm Unstable condition Stable condition Stable condition Unstable condition Polymorphic AF with AF with aberrancy Adenosine VT, VF WPW or AF with benign WPW Cardioversion–defibrillation Termination No termination VT Differential Diagnosis and SVT with Cardioversion; IV Treatment of Wide- aberrancy, procainamide, AVRT (WPW), sotalol, lidocaine, Complex Tachycardias. idiopathic VT or amiodarone