Ghulam Haider, a 65-year-old businessman, presented with a 30-minute history of palpitations and trembling. He has a history of similar self-limiting episodes over the past 25 years. Examination found a heart rate of 140 and fine tremors in his hands. Tests included an echocardiogram showing 60% ejection fraction and an electrophysiology study found atrioventricular nodal reentrant tachycardia. Radiofrequency ablation was performed to treat the arrhythmia.

2. 
Case Presentation
Dr Hania Afzal
Resident Medicine

3. 
 Biodata
 Name: Ghulam Haider
 Age: 65 years
 Occupation: owns a business
 Resident: Stadium road Sargodha

4. 
 Presenting Complain:
 Palpitations 30 minutes
 Discomfort/ 20 minutes
feeling of trembling body

5. 
 HOPC
My patient was in his usual state of health till day of
presentation when he suddenly developed palpitations while
doing his routine daily chores. Palpitations were severe
enough to abstain patient from doing any activity and were
associated with trembling body and generalized feeling of
discomfort but not with chest pain, diaphoresis, vomiting,
loss of consciousness or any other complain.

6. 
He has history of self limiting episodes of palpitations for last
25 years. 1st episode was 25 years back while sitting in office
and remained for just 1-2 minutes. Duration and frequency of
episodes increased gradually.
He tried to receive medical care for this issue but never
reported to a hospital during these episodes before and in
between episodes he was physically fit.

7. 
 Past Medical Hx
He had elective PCI 2 years back when he had angiography
due to same, recurrent complains. Stent was placed in 1
vessel.
 Past Surgical Hx
He had laprotomy in 1988 due to ruptured appendix

8. 
 Drug Hx
Bisoprolol, Pantoprazole
 Vaccination Hx
Fully vaccinated with covid vaccine
 Personal Hx
Normal appetite
Normal sleep wake cycle
Normal bowel habits
No hx of allergies or addictions

9. 
 Transfusion Hx
He received blood transfusion during laprotomy
 Family Hx
Not significant
 Socioeconomic Hx
He has 1 son, 3 daughters all married and settled and lives in
his own home with his wife
 Systemic Inquiry:
Insignificant

10. 
 Clinical examination
A middle aged male patient, lying on hospital bed, well
oriented in time, place and person (GCS 15/15) with vitals of
 BP: 120/80mmHg, Pulse: 140/min, SaO2: 94% on air
RR: 16/min, Temp: afebrile,
Regular, good volume pulse with no radioradial or
radiofemoral delay
GPE

11. 
Jaundice: -ive
Palor: -ive
Clubbing: -ive
Koilonychia: -ive
Edema: -ive
Neck Swelling: -ive
Lymph Nodes: -ive
Fine tremors in his hands

12. 
Unremarkable with bilateral clear chest, tachycardia on CVS
examination, normal CNS and soft non tender abdomen.
Systemic examination

13. 

14. 
 Carotid Massage
 Valsalva Manouver
Management

15. 

16. 
 CBC:
Hb: 16.4, TLC: 5.4, plt: 254
 TSH: 1.4
 LFTs
 RFTs
 K
 HBsAg, Anti HCV
 Xray Chest
 Echo 60% EF
 ETT negative for ischemia with 80% of THR achieved
Investigations

17. 
 EFS
AVNRT
 RFA to Koch’s triangle

18. 
Supra Ventricular
Tachycardia

19. 
 Regular tachycardia requiring atrial or AV nodal tissue for
initiation and maintenance
 Usually narrow QRS complex
 Types
 AVNRT
 AVRT
 Atrial tachycardias are also included
What it is…..

20. 
Tachycardia due to re entry in a circuit involving AV node
and 2 right atrial pathways
 A superior fast
(short conduction T,
Long ERP)
 An Inferior slow
(long conduction time
Short ERP)
AVNRT

21. 
Abnormal band of conducting tissue between atria and
ventricles containing Na channel rich fibres
 Concealed pathway (retrograde)
 Manifest pathway (anterograde)
If Afib develops…. Can be lethal
Digoxin and verapamil should not be used, ablation is
preferred Rx
AVRT/WPW

22. 
 Inherited Conditions
 Structural abnormalities
 Coronary artery disease
 COPD
 Thyrotoxicosis
 Pulmonary embolism
Risk factors

23. 
ECG,
IV,
O2
if
hypoxic
Is rhythm
regular?
Yes
ECG monitor,
vagal manouvers
No Treat as afib
ER Management

24. 
Adenosine 6mg,then 12
,then 12 /verapamil 2.5-
5mg over 2 minutes
Vagal Manouvers
Adverse signs
a)Shock b) HF c) LOC
d) HR > 200
ER Management

25. 
 If adverse signs are present
treat with electrical cardioversion i.e synchronized DC
schock under sedation
 If no adverse signs
 IV metoprolol (1-10mg)
 Digoxin (max 500µg over 35 min)
 Amiodarone

26. 
Once sinus rhythm achieved
 Observe pt and educate them
 Investigate for cause and manage
 Prophylactic beta blockers, verapamil or flecanide
 Catheter ablation
Rx

27. 