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SUPRAVENTRICULAR
TACHYCARDIAS:
Recognition and Management
Mandeep Bhargava, MD
Cleveland Clinic
Cleveland, OH USA
QUESTION
•
The following arrhythmia is most likely to
respond to intravenous Adenosine
1.
2.
3.
4.
Atrial Tachycardia
AV reciprocating tachycardia
Atrial Flutter
Atrial Fibrillation
QUESTION
•
The following arrhythmia is most likely to
respond to intravenous Adenosine
1.
2.
3.
4.
Atrial Tachycardia
AV reciprocating tachycardia
Atrial Flutter
Atrial Fibrillation
Classification of SVTs
– Sinus Node Dependent
• Sinus tachycardia
• Inappropriate sinus tachycardia/POTS
• Sinus node reentry
– AV Node Dependent
• AV node reentry (AVNRT), Junctional
• AV reciprocating tachycardia (AVRT/ORT)
• PJRT, Mahaim
– Atrial Dependent (AV node independent)
• Atrial tachycardia
• Atrial flutter
• Atrial fibrillation
Classification of SVTs
– Sinus Node Dependent
• Sinus tachycardia
• Inappropriate sinus tachycardia/POTS
• Sinus node reentry
– AV Node Dependent
• AV node reentry (AVNRT), Junctional
• AV reciprocating tachycardia (AVRT/ORT)
• PJRT, Mahaim
– Atrial Dependent (AV node independent)
• Atrial tachycardia
• Atrial flutter
• Atrial fibrillation
Electrophysiologic Classification
 Focal
– Radial/Centrifugal activation
– Ablation of focus of origin interrupts the tachycardia
 Macro-reentrant
– Circular/continuous pattern of activation
– Needs ablation of a critical isthmus
The Common SVTs
• AV Nodal Re-entry tachycardia (60%)
• AV reciprocating (Orthodromic) Tachycardia
(30%)
• Atrial Tachycardia (10%)
TYPICALLY NARROW QRS TACHYCARDIAS
AVNRT
AVNRT: Initiation of reentry
*
S
Sinus
*
F
S
Jump
F
S
Echo
F
F
AVNRT
AVNRT
Typical
Atypical
INITIATION OF AVNRT
Accessory Pathways
Wolff-Parkinson-White Syndrome
Manifest:
Delta Wave
Short PR Interval
Wide QRS
Concealed:
Normal ECG
WPW Syndrome: Pre-excitation + palpitations
Concealed Bypass Tracts
Accessory Pathways
Usually non decremental
5% multiple
Shorter refractory period so conduct faster
Can be persistent or intermittent pre-excitation
Especially dangerous in atrial fibrillation
Lower threshold for invasive evaluation
Clinical Presentation: WPW Syndrome
Orthodromic Tachycardia/AVRT
Short RP but not too short: AVRT
PR and RP relationship
Short RP: Typical AVNRT, AVRT, less commonly Atrial tachycardia
Long RP: Atypical AVNRT, PJRT, Atrial tachycardia
Long RP Tachycardia
Long RP Tachycardia: Atrial Tachycardia
Atypical AVNRT
ORT with a slow decremental pathway (PJRT)
Atrial Tachycardias
•
•
Tachycardia independent from AV node (usually 180-240 bpm)
Adenosine causes AV block without any effect on the tachycardia
•
Isoelectric baseline between P waves; warm up and cool down
Atrial Tachycardias
Focal Atrial Tachycardias
•
•
•
•
•
•
•
•
•
Can very often be nonsustained
When incessant, can cause tachycardiomyopathy
Rates can change with autonomic tone
Can masquerade as sinus tachycardia
40% may terminate with Adenosine
Often misdiagnosed as AF
Do not need anticoagulation
Usually long RP tachycardias
PV tachycardias are precursors for atrial fibrillation
Atrial Tachycardias
Initiation of Atrial Tachycardia
Multifocal Atrial Tachycardia
> 3 foci; suspect pulmonary disease
Atrial tachycardia vs flutter
 Rate cut off (240-250)
 Isoelectric baseline vs continuous activity
 Focal (AT) versus re-entrant (AFl)
 Warm up and Cool down phenomena
 Adrenergic response
 TCL variation (typically less than 2% in atrial
flutter)
Typical Atrial flutter
Atrial tachycardia vs flutter
Triggers and substrate
Reentrant
circuits
PV foci
Atrial fibrillation
Wide complex SVTs
•
•
•
•
SVT in a patient with pre-existing BBB
SVT with right or left bundle aberrancy
Antidromic tachycardia
Atrial tachycardia or fibrillation with preexcitation
Wide complex SVTs
Wide complex SVTs
SVT with ABERRANCY
ANTIDROMIC TACHYCARDIA
CAN A VT SHOW TYPICAL
BUNDLE BRANCH BLOCK
RBBB tachycardia
Vs > As
Pearl: Watch the T wave morphology; is there a P wave buried
FASCICULAR VT
Pitfall: They can look like typical bundle branch blocks
BUNDLE BRANCH REENTRY
Pitfall: They can look like typical bundle branch blocks
BUNDLE BRANCH REENTRY
AF with pre-excitation
WPW and SCD:
AF degenerating into VF
Rapid ventricular rates during AF (<250 ms RR)
Coumel’s Tachycardia
Orthodromic Tachycardia
with LBBB (left sided AP)
Tele Monitoring: Lead II on top and
Lead V1 bottom
Localization of APs
• Look for the polarity of the Delta Wave:
• TRY TO LOOK FOR MAXIMAL PRE-EXCITATION
• Right or Left:
– V1
• Anterior or Posterior:
– II, III, aVF: Negative in posterior (inferior pathways)
– II, III, aVF: Positive in anterior (superior pathways)
• Lateral or Septal:
– aVL , aVR negative in respective lateral pathways
– Transition in mid precordial leads in septal pathways
TREATMENT OF AVNRT/AVRT
• Acute
– Vagal maneuvers and I/V Adenosine: Class I
– I/V Beta blockers, Ca channel blockers: Class IIa
– Hemodynamic compromise:
• Synchronized DC cardioversion
• Long term
– AV nodal blockers
– Catheter ablation
PREGNANCY AND SVT
• Acute
– Vagal maneuvers, Adenosine equally safe (Class I)
– DC cardioversion safe if directed away from the
uterus (Class I)
– I/V Beta blockers may be used (Class IIa)
– I/V CaCB, Amio, Procainamide (Class IIb)
• Long term
– “Safer” Drugs: Metoprolol, Digoxin, Class ICs,
Propranolol, Sotalol, Verapamil (Class IIa)
– Catheter ablation: Minimize fluoro to < 50 mGy and
avoid first trimester (Class IIb)
Drug therapy for WPW Syndrome
Management of SVTs: Acute
• AV node independent tachycardias (AT, Afl, AF)
• Antidromic Tachycardia or AF with Pre-excitation
– I/V Ibutilide
– I/V Procainamide
– Cardioversion
Adenosine and AV node blockers are contraindicated in
AF with pre-excitation
Catheter Ablation
• Drug refractoriness / intolerance
• Patient preference
• Severe symptoms: Syncope/HF/risk of SCD
• Tachycardia induced cardiomyopathy
• Usually long term therapy of choice for SVTs
Differentiation of SVT
Rate
Regularity: focal or re-entrant
Mode of initiation/termination
Atrial ectopy – AT, AVRT, AVNRT
Ventricular ectopy – AVRT
PR prolongation
QRS morphology – Narrow vs wide
Effect of BBB/aberration/Antidromic
Effect of vagal maneuvers, adenosine
Presence of AV block
Rules out AVRT, AVNRT unlikely
P waves
Pattern +ve or -ve in inferior leads
RP/PR relationship
Summary for the Boards
• Atrial tachycardia and adenosine response
• AVNRT – ECG with r’V1, induction with a long AH
“jump,” echo, and simultaneous A/V
• WPW AVRT – L lateral accessory pathway
• BBB aberration with longer CL, indicating
ipsilateral AP
• Atrial fibrillation and WPW
Useful references:
1. Blomstrom-Lundqvist et al. ACC/AHA/ESC Guidelines for Management of Patients with
Supraventricular Arrhythmias. Circulation 2003;108:1871-1909.
2. Ganz LI, Friedman PL. Supraventricular tachycardia. NEJM 1995;332:162-173.
Case 1
• A 19y/o female presents to the ED. Long history of
palpitations which tend to occur after exercise. Typically
last a few minutes before terminating spontaneously.
Most recent episode prompting the ED visit lasted for 20
minutes.
• Admits to occasional lightheadedness. She has an
episode of syncope about 15 months ago. history of
syncope
• Very active on college soccer and cross-country team
EKG in ED
What treatment strategy should be advised?
•
•
•
•
•
1. Intravenous Adenosine
2. Intravenous Procainamide
3. Slow infusion of intravenous diltiazem 10mg/hour
4. Schedule for EP study and possible ablation
5. Immediate defibrillation
What treatment strategy should be advised?
•
•
•
•
•
1. Intravenous Adenosine
2. Intravenous Procainamide
3. Slow infusion of intravenous diltiazem 10mg/hour
4. Schedule for EP study and possible ablation
5. Immediate defibrillation
What would be the next best treatment
strategy to be advised?
•
•
•
•
•
1. Discharge home with instructions for vagal maneuvers
2. Start Amiodarone
3. Start Metoprolol or Diltiazem
4. Schedule for EP study and possible ablation
5. Class IC antiarrhythmic drug with anticoagulation
What would be the next best treatment
strategy to be advised?
•
•
•
•
•
1. Discharge home with instructions for vagal maneuvers
2. Start Amiodarone
3. Start Metoprolol or Diltiazem
4. Schedule for EP study and possible ablation
5. Class IC antiarrhythmic drug with anticoagulation
Case 2
• 24 year old male
• Presents to the ED with palpitations which
started while doing heavy lifting at home
• No history of syncope, presyncope but had a
similar episode 6 years ago which spontaneously
termination
• Echo: Normal
12 lead in ED
What therapy do you recommend
for this patient?
•
•
•
•
•
1. Provide instructions on vagal maneuvers.
2. Start flecainide
3. Start amiodarone
4. Schedule EP study and ablation
5. Either 1 or 4
What therapy do you recommend
for this patient?
•
•
•
•
•
1. Provide instructions on vagal maneuvers.
2. Start flecainide
3. Start amiodarone
4. Schedule EP study and ablation
5. Either 1 or 4
The patient opts for ablation.
What is the target?
•
•
•
•
•
1. Isolation of the pulmonary veins
2. A line of block between the TV and IVC
3. Ablation of the fast pathway
4. Ablation of the slow pathway
5. Sinus node modification
The patient opts for ablation.
What is the target?
•
•
•
•
•
1. Isolation of the pulmonary veins
2. A line of block between the TV and IVC
3. Ablation of the fast pathway
4. Ablation of the slow pathway
5. Sinus node modification
Case 3
• 45 year old male presents with episodes of
intermittent heart racing and shortness of breath
for the last 2 weeks. He has no lightheadedness or
syncope and denies any chest pain
• He is a known smoker, consumes beer, is obese
and hypertensive.
• Echo shows LVEF of 30% function with normal
valves. He presents for an evaluation to the OPD
and is found to have a rapid heart rate, BP of
130/70 mmHg, is euvolemic and has no murmurs
with clear lungs
The patient has a 12 lead EKG
HR 240 bpm
Which of the following is a
differential diagnosis?
1. AV nodal re-entry tachycardia
2. AV reciprocating tachycardia
3. Atrial tachycardia
4. Atrial flutter
5. All of the above
Which of the following is a
differential diagnosis?
1. AV nodal re-entry tachycardia
2. AV reciprocating tachycardia
3. Atrial tachycardia
4. Atrial flutter
5. All of the above
The patient was taken to the ER
and given 6 mg i/v Adenosine
Which of the following is not a good
treatment option for him at this time?
1. Cavotricuspid isthmus ablation
2. AVJ ablation and pacemaker
3. TEE, Heparin, DC cardioversion
4. Warfarin and beta blocker
5. Dabigatran, TEE, DC cardioversion
Which of the following is not a good
treatment option for him at this time?
1. Cavotricuspid isthmus ablation
2. AVJ ablation and pacemaker
3. TEE, Heparin, DC cardioversion
4. Warfarin and beta blocker
5. Dabigatran, TEE, DC cardioversion
THANK YOU
Typical catheter placement
• High right atrium
• Coronary sinus
• His bundle
• RV apex
RAO
LAO
HRA
HIS
HIS
CS
HRA
CS
RVA
RVA
600/300
AVNRT from
the inside
AVRT from the inside: Right
AVRT from the inside: Left
In which region would you expect the AP?
A. R posteroseptal
B. L posterior
C. R anteroseptal
D. L lateral
1
In which region would you expect the AP?
A. R posteroseptal
B. L posterior
C. R anteroseptal
D. L lateral
1
In which region would you expect the AP?
A. R posteroseptal
B. L posterior
C. R anteroseptal
D. L lateral
2
In which region would you expect the AP?
A. R posteroseptal
B. L posterior
C. R anteroseptal
D. L lateral
2
In which regions would you expect the AP?
A. Posteroseptal
B. Right lateral
C. R anteroseptal
D. L lateral
3
In which regions would you expect the AP?
A. Posteroseptal
B. Right lateral
C. R anteroseptal
D. L lateral
3
Antiarrhythmic Drugs
• Know your contraindications
• Flecainide/Propafenone (Class IC: Na channel blockers)
– CAD/structural heart disease/LVH
• Sotalol/Dofetilide (Class III: K channel blockers)
– Renal dysfunction, QT prolongation, Asthma
• Amiodarone
– Lung/Thyroid/Liver/Skin
• Disopyramide
– Prostate/Dryness: Good for HCM patients
DC Cardioversion
• Hemodynamically significant arrhythmias
• Unresponsive to drug therapy
• For atrial fibrillation and flutter
– Ensure 3 weeks of prior anticoagulation / TEE /
duration less than 48 hours
– Therapeutic anticoagulation during DCC
– Anticoagulation for 4-6 weeks post DCC
ABLATION OF AVNRT
ABLATION OF AVRT
ABLATION OF ATRIAL FLUTTER
ABLATION OF AFib
PV ANTRUM ISOLATION
Atrial Tachycardias
Right sided Atrial Tachycardias
Kistler et al, JACC 2006
Left sided Atrial Tachycardias
Kistler et al, JACC 2006
Typical Atrial flutter


Re-entrant RA activation

Bounded anteriorly by TA; posteriorly by SVC, IVC, Eustachian ridge
and functional block in CT

90% CCW; Caudal ant/lateral and cranial post/septal

10% are Reverse typical atrial flutters
EKG:
– Sawtooth, -ve in II, III, aVF
– V1 usually positive but can be biphasic or positive
– V5, V6, negative
– I, aVL low voltage
– Can be atypical patterns in CW flutter
AV Nodal Reentry Tachycardia
– Pathophysiology: Reentry
– Types: Typical (Slow-fast), Atypical (Fast-slow,
slow-slow)
– EKG:
– Absence of P waves/Short VA
– Usually no AV block
– RP usually less than 7oms
– Pseudo r and s waves
– Initiation with a PAC and prolonged AH
Focal Junctional Tachycardia
– Focal:
• Usually in children, automaticity, responds to
flecainide and beta blockers
• 5-10% risk of CHB with ablation
– Non paroxysmal Junctional
• Warm up and cool down phases
• Usually induced by MI, hypokalemia, digitalis
Focal Junctional Tachycardia
Case 1
•
•
•
•
•
•
A 19y/o female presents through the ED with palpitations.
Long history of palpitations which tend to occur after exercise.
– Typically last a few minutes before terminating spontaneously.
– Most recent episode prompting the ED visit lasted for 20
minutes.
Admits to associated LH. No history of syncope
Otherwise healthy. No meds or illicit drug use
Very active on school soccer team and cross-country team
No family history of SCD
EKG in ED
What treatment strategy should be advised?
• 1. Intravenous Adenosine
• 2. Intravenous Procainamide
• 3. Slow infusion of intravenous diltiazem
10mg/hour
• 4. Schedule for EP study and possible ablation
• 5. Immediate defibrillation
What treatment strategy should be advised?
• 1. Intravenous Adenosine
• 2. Intravenous Procainamide
• 3. Slow infusion of intravenous diltiazem
10mg/hour
• 4. Schedule for EP study and possible ablation
• 5. Immediate defibrillation
What would be the next best treatment
strategy to be advised?
• 1. Discharge home with instructions for vagal
maneuvers
• 2. Start Amiodarone
• 3. Start Metoprolol or Diltiazem
• 4. Schedule for EP study and possible ablation
• 5. Class IC antiarrhythmic drug with
anticoagulation
What would be the next best treatment
strategy to be advised?
• 1. Discharge home with instructions for vagal
maneuvers
• 2. Start Amiodarone
• 3. Start Metoprolol or Diltiazem
• 4. Schedule for EP study and possible ablation
• 5. Class IC antiarrhythmic drug with
anticoagulation
Case 2
• 42 year old male
• History of hypertension controlled on HCTZ
• Presents to the ED with palpitations which
started while doing heavy lifting at home
• Admits to LH, but no syncope, presyncope
• No CP/SOB.
• No history of syncope or FH of SCD
• Echo: Normal
12 lead in ED
What therapy do you recommend
for this patient?
• 1. Provide instructions on vagal
maneuvers.
• 2. Start flecainide
• 3. Start amiodarone
• 4. Schedule EP study and ablation
• 5. Either 1 or 4
What therapy do you recommend
for this patient?
• 1. Provide instructions on vagal
maneuvers.
• 2. Start flecainide
• 3. Start amiodarone
• 4. Schedule EP study and ablation
• 5. Either 1 or 4
The patient opts for ablation.
What is the target?
• 1. Isolation of the pulmonary veins
• 2. Creation of a line of block between the
TV and IVC
• 3. Ablation of the fast pathway
• 4. Ablation of the slow pathway
• 5. Sinus node modification
The patient opts for ablation.
What is the target?
• 1. Isolation of the pulmonary veins
• 2. Creation of a line of block between the
TV and IVC
• 3. Ablation of the fast pathway
• 4. Ablation of the slow pathway
• 5. Sinus node modification
Case 3
• 47 year old male with no prior medical history presents
with 6 weeks of progressive DOE
• Now gets SOB walking a single block
• Admits to tobacco use, occasional alcohol and rare
cocaine (none in last month)
• Not currently on medications
• No syncope or FH of SCD
• BP 112/64, Pulse 125
• On exam there is evidence of mild volume overload
12 lead EKG
Cardiac studies
• TTE:
– EF 30%
– Mild MR
– Trivial TR
• Left heart cath:
– Normal coronaries
What is the appropriate next step?
• 1. Initiate LMWH and warfarin. Perform TEE
and if negative proceed to DCC
• 2. Urgent cardioversion. No additional studies
indicated
• 3. Elective cardioversion after initiation of
warfarin and 3 weeks therapeutic INRs
• 4. Start ACE-I, beta-blocker and flecainide
What is the appropriate next step?
• 1. Initiate LMWH and warfarin. Perform TEE
and if negative proceed to DCC
• 2. Urgent cardioversion. No additional studies
indicated
• 3. Elective cardioversion after initiation of
warfarin and 3 weeks therapeutic INRs
• 4. Start ACE-I, beta-blocker and flecainide
The patient’s EF normalizes several weeks
after DCC and he is requesting EPS and
ablation. What is the target of ablation?
• 1. Ablation is not indicated at this time
• 2. Isolation of the pulmonary veins
• 3. Creation of a line of block between the
TV and IVC
• 4. Numbers 2 and 3
• 5. AV node modification
The patient’s EF normalizes several weeks
after DCC and he is requesting EPS and
ablation. What is the target of ablation?
• 1. Ablation is not indicated at this time
• 2. Isolation of the pulmonary veins
• 3. Creation of a line of block between the
TV and IVC
• 4. Numbers 2 and 3
• 5. AV node modification
Case 4
54 year old male with a history of recurrent presyncopal spells
who has had short runs of palpitations for the last 8 years.
He currently had an episode of palpitations while sitting on
his computer desk and feels that this was preceded by a
bout of palpitations. He has no orthostasis, carotid sinus
hypersensitivity and had a normal physical exam
He was admitted for monitoring and his work up showed the
following
EKG at baseline: Normal
CxR: No cardiomegaly
Normal blood counts
Echo: Normal LV size and function; Normal valves
Stress test: No ischemia
Tele Monitoring: Lead II on top and Lead V1
bottom
Intensive Review of Cardiology
Which of the following is the most likely
pathology in this patient
1. Fascicular ventricular tachycardia
2. Left lateral accessory pathway
3. Mahaim fibres (Atriofascicular
tachycardia)
4. Dual AV nodal physiology
5. Right posteroseptal accessory
pathway
Which of the following is the most likely
pathology in this patient
1. Fascicular ventricular tachycardia
2. Left lateral accessory pathway
3. Mahaim fibres (Atriofascicular
tachycardia)
4. Dual AV nodal physiology
5. Right posteroseptal accessory
pathway
Case 7
• 28 year old male presents with episodes of
skipping beats and fatigue for the last 2 months
• He denies chest pain, syncope and has no family
history of sudden cardiac death
• He feels the episodes are more frequent at rest
when he is lying in the bed and sitting at his
computer desk. He is sedentary and has not
noted any change in his effort tolerance recently.
He has a normal physical examination
• He has a normal EKG at baseline with a heart
rate of 90 bpm. He is a little anxious.
24 hour holter
Heart rates 58 to 128 bpm; avg 73 bpm
Which of the following is unlikely
in this patient?
1. Sinus node re-entry tachycardia
2. AV node re-entry tachycardia
3. Atrial tachycardia
4. Persistent junctional
reciprocating tachycardia
Which of the following is unlikely
in this patient?
1. Sinus node re-entry tachycardia
2. AV node re-entry tachycardia
3. Atrial tachycardia
4. Persistent junctional
reciprocating tachycardia
Other investigations
• Normal thyroid profile
• Normal Chest X ray
• Holter: 33% of beats in PACs and
nonsustained tachycardia
• Echo
• LV 62/52 mm; LA 4.2
• LVEF 28%; Moderate MR
• No wall motion abnormality
Which of the following is the next best step
in the management for this patient?
1. Propafenone
2. EP study and catheter ablation
3. Long acting Metoprolol
4. Carvedilol
5. Dofetilide
Intensive Review of
Cardiology
Sinus Tachyarrhythmias
Physiological Sinus Tachycardia
Anatomical shift in the site of impulse generation
Postural Orthostatic Tachycardia Syndrome
Inappropriate Sinus Tachycardia
Sinus Node Re-entry Tachycardia
Paroxysmal, terminates with adenosine
Look for P wave polarity and morphology
Which of the following is the next best step
in the management for this patient?
1. Propafenone
2. EP study and catheter ablation
3. Long acting Metoprolol
4. Carvedilol
5. Dofetilide
Atrial Tachycardias
RBBB tachycardia
Management of SVTs:
Long Term
• Know your options
• AV nodal blockers (BB, CaCB)
– AV node dependent tachycardias: AVNRT, AVRT
• Antiarrhythmic drugs
– AV independent tachycardias: Atrial tach, WPW