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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