Supraventricular tachycardia differential diagnosis: Difference between revisions

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{{Supraventricular tachycardia}}
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==Overview==
==Differentiating Among the Different Types of Supraventricular Tachycardia==
 
The individual subtypes of SVT can be distinguished from each other by certain physiological and electrical characteristics, many of which present in the patient's EKG. [[Supraventricular tachycardias]] must be differentiated from each other because the management strategies may vary:
==Differentiating Supraventricular Tachycardia from other Diseases==
{| class="wikitable"
The individual subtypes of SVT can be distinguished from each other by certain physiological and electrical characteristics, many of which present in the patient's EKG.
|+
 
!
[[Supraventricular tachycardias]] must be differentiated from each other because the management strategies may vary:
!Epidemiology
 
!Rate
===[[Atrial Fibrillation]]===
!Rhythm
*''Rate'': 110 to 180 bpm
!P waves
*''Rhythm'': Irregularly irregular
!PR Interval
*''[[P waves]]'': Absent, fibrillatory waves
!QRS complex
*''[[PR interval]]'': Absent
!Response to maneuvers
*''[[QRS complex]]'': Less than 0.12 seconds, consistent, and normal in morphology in the absence of abberant conduction
|-
*''Response to Maneuvers'': Does not break with [[adenosine]] or [[vagal maneuvers]]
|'''Sinus Tachycardia'''
*''Epidemiology and Demographics'':  More common in the elderly, following [[bypass surgery]], in mitral valve disease, [[hyperthyroidism]]
|
 
|Greater than 100 bpm
===[[Atrial Flutter]]===
|Regular
*''Rate'': 75 (4:1 block), 100 (3:1 block) and 150 (2:1 block) bpm, but 150 is most common
|Upright, consistent, and normal in morphology
*''Rhythm'': Regular
|0.12–0.20 sec and shortens with high heart rate
*''[[P waves]]'': Sawtooth pattern of [[P waves]] at 250 to 350 beats per minute
|Less than 0.12 seconds, consistent, and normal in morphology
*''[[PR interval]]'': Varies depending upon the magnitude of the block, but is short
|May break with [[vagal maneuvers]]
*''[[QRS complex]]'': Less than 0.12 seconds, consistent, and normal in morphology
|-
*''Response to Maneuvers'': Conduction may vary in response to drugs and maneuvers dropping the rate from 150 to 100 or to 75 bpm
|'''Atrial Fibrillation'''
*''Epidemiology and Demographics'': More common in the elderly, after alcohol
|More common in the elderly, following [[bypass surgery]], in mitral valve disease, [[hyperthyroidism]]
*''Pathophysiology'':
|110 to 180 bpm
 
|Irregularly irregular
===[[AV Nodal Reentry Tachycardia]]===
|Absent, fibrillatory waves
*''Rate'':  In adults the range is 140-250 bpm, but in children the rate can exceed 250 bpm.
|Absent
*''Rhythm'': Regular
|Less than 0.12 seconds, consistent, and normal in morphology in the absence of aberrant conduction
*''[[P waves]]'': The [[p wave]] is usually superimposed on or buried within the [[QRS complex]]
|Does not break with [[adenosine]] or [[vagal maneuvers]]
*''[[PR interval]]'': The [[PR interval]] cannot be calculated as the [[p wave]] is generally obscured by the [[QRS complex]]. In uncommon AVNRT, the [[p wave]] can appear after the [[QRS complex]] and before the [[T wave]], and in atypical AVNRT, the [[p wave]] can appear just before the [[QRS complex]].
|-
*''[[QRS complex]]'': Less than 0.12 seconds, consistent, and normal in morphology in the absence of abberant conduction, [[QRS alternans]] may be present
|'''Atrial Flutter'''
*''Response to Maneuvers'': May break with [[adenosine]] or [[vagal maneuvers]]
|More common in the elderly, after alcohol
*''Epidemiology and Demographics'': Accounts for 60%-70% of all SVTs. 80% to 90% of cases are due to antegrade conduction down a slow pathway and retrograde up a fast pathway.
|75 (4:1 block), 100 (3:1 block) and 150 (2:1 block) bpm, but 150 is more common
 
|Regular
===[[AV Reciprocating Tachycardia]]===
|Sawtooth pattern of [[P waves]] at 250 to 350 beats per minute
*''Rate'': More rapid than AVNRT
|Varies depending upon the magnitude of the block, but is short
*''Rhythm'':
|Less than 0.12 seconds, consistent, and normal in morphology
*''[[P waves]]'':
|Conduction may vary in response to drugs and maneuvers dropping the rate from 150 to 100 or to 75 bpm
*''[[PR interval]]'':
|-
*''[[QRS complex]]'': Less than 0.12 seconds, consistent, and normal in morphology
|'''AV Nodal Reentry Tachycardia (AVNRT)'''
*''Response to Maneuvers'': May break with [[adenosine]] or [[vagal maneuvers]]
|Accounts for 60%-70% of all SVTs. 80% to 90% of cases are due to antegrade conduction down a slow pathway and retrograde up a fast pathway.
*''Epidemiology and Demographics'': More common in males, whereas AVNRT is more common in females, occurs at a younger age.
|In adults the range is 140-250 bpm, but in children the rate can exceed 250 bpm
*''Pathophysiology'':*[[AV reentrant tachycardia|Atrioventricular reentrant tachycardia]] (AVRT) also results from a reentry circuit, although one physically much larger than AVNRT.  One portion of the circuit is usually the AV node, and the other, an abnormal accessory pathway from the atria to the ventricle.  [[Wolff-Parkinson-White syndrome]] is a relatively common abnormality with an accessory pathway, the [[Bundle of Kent]] crossing the A-V valvular ring.
|Regular
**'''In orthodromic AVRT''', atrial impulses are conducted down through the AV node and retrogradely re-enter the atrium via the accessory pathway. A distinguishing characteristic of orthodromic AVRT can therefore be a p-wave that follows each of its regular, narrow QRS complexes, due to retrograde conduction. 
|The [[P wave]] is usually superimposed on or buried within the [[QRS complex]]
**'''In antidromic AVRT''', atrial impulses are conducted down through the accessory pathway and re-enter the atrium retrogradely via the AV node.  Because the accessory pathway initiates conduction in the ventricles ouside of the bundle of His, the QRS complex in antidromic AVRT is often wider than usual, with a [[Wolff-Parkinson-White syndrome#diagnosis|delta wave]].
|Cannot be calculated as the P wave is generally obscured by the [[QRS complex]]
 
|Less than 0.12 seconds, consistent, and normal in morphology
===[[Inappropriate Sinus Tachycardia]]===
|May break with [[adenosine]] or [[vagal maneuvers]]
*''Rate'': A resting [[sinus tachycardia]] is usually (but not always) present. The mean [[heart rate]] during 24 hrs of monitoring is > 95 beats per minute. A nocturnal reduction in [[heart rate]] is present. There is an inappropriate [[heart rate]] response on exertion.
|-
*''Rhythm'': Regular
|'''AV Reciprocating Tachycardia (AVRT)'''
*''[[P waves]]'': Normal morphology and precede the [[QRS complex]]
|More common in males, whereas AVNRT is more common in females, occurs at a younger age.
*''[[PR interval]]'': Normal and < 0.20 seconds
|More rapid than AVNRT
*''[[QRS complex]]'': Less than 0.12 seconds, consistent, and normal in morphology
|Regular
*''Response to Maneuvers'': Does not break with [[adenosine]] or [[vagal maneuvers]]
|A retrograde P wave is seen either at the end of the QRS complex or at the beginning of the ST segment
*''Epidemiology and Demographics'':
|Less than 0.12 seconds
*''Pathophysiology'': These patients have no apparent heart disease or other causes of sinus tachycardia. IST is thought to be due to abnormal autonomic control.
|Less than 0.12 seconds, consistent, and normal in morphology
 
|May break with [[adenosine]] or [[vagal maneuvers]]
===[[Junctional Tachycardia]]===
|-
*''Rate'': > 60 beats per minute
|'''Inappropriate Sinus Tachycardia'''
*''Rhythm'': Regular
|The disorder is uncommon. Most patients are in their late 20s to early 30s. More common in women.
*''[[P waves]]'': Usually inverted, may be burried in the QRS complex
|> 95 beats per minute. A nocturnal reduction in heart rate is present. There is an inappropriate heart rate response on exertion.
*''[[PR interval]]'': The [[p wave]] is usually buried in the [[QRS complex]]
|Regular
*''[[QRS complex]]'': Less than 0.12 seconds, consistent, and normal in morphology
|Normal morphology and precede the [[QRS complex]]
*''Response to Maneuvers'': Does not break with [[adenosine]] or [[vagal maneuvers]]
|Normal and < 0.20 seconds
*''Epidemiology and Demographics'': Common after [[heart surgery]], [[digoxin toxicity]], as an escape rhythm in [[AV block]]
|Less than 0.12 seconds, consistent, and normal in morphology
 
|Does not break with [[adenosine]] or [[vagal maneuvers]]
===[[Multifocal Atrial Tachycardia]]===
|-
 
|'''Junctional Tachycardia'''
*''Rate'': Atrial rate is > 100 beats per minute (bpm)
|Common after [[heart surgery]], [[digitalis toxicity]], as an escape rhythm in [[AV block]]
*''Rhythm'': Irregular
|> 60 beats per minute
*''[[P waves]]'': [[P waves]] of varying morphology from at least three different foci, absence of one dominant atrial pacemaker, can be mistaken for [[atrial fibrillation]] if the [[P waves]] are of low amplitude
|Regular
*''[[PR interval]]'': Variable [[PR interval]]s, [[RR interval]]s, and [[PP interval]]s
|Usually inverted, may be burried in the QRS complex
*''[[QRS complex]]'': Less than 0.12 seconds, consistent, and normal in morphology
|The [[P wave]] is usually buried in the [[QRS complex]]
*''Response to Maneuvers'': Does not terminate with [[adenosine]] or [[vagal maneuvers]]
|Less than 0.12 seconds, consistent, and normal in morphology
*''Epidemiology and Demographics'': * High incidence in the elderly and in those with [[COPD]]
|Does not break with [[adenosine]] or [[vagal maneuvers]]
 
|-
===[[Sinus Node Reentry Tachycardia]]===
|'''Multifocal Atrial Tachycardia (MAT)'''
*''Rate'':
|High incidence in the elderly and in those with [[COPD]]
*''Rhythm'':
|Atrial rate is > 100 beats per minute (bpm)
*''[[P waves]]'': Upright [[P waves]] precede each regular, narrow [[QRS]] complex
|Irregular
*''[[PR interval]]'':
|P waves of varying morphology from at least three different foci
*''[[QRS complex]]'': Less than 0.12 seconds, consistent, and normal in morphology
|Variable [[PR interval]]s, [[RR interval]]s, and [[PP interval]]s
*''Response to Maneuvers'': Although it cannot be distinguished on the surface 12 lead EKG from [[sinus tachycardia]], SA node reentry tachycardia does often terminate with [[vagal maneuvers]] unlike [[sinus tachycardia]].
|Less than 0.12 seconds, consistent, and normal in morphology
*''Epidemiology and Demographics'':
|Does not terminate with [[adenosine]] or [[vagal maneuvers]]
 
|-
===[[Sinus tachycardia]]===
|'''Sinus Node Reentry Tachycardia'''
*''Rate'':  Greater than 100.
|
*''Rhythm'':  Regular.
|100 to 150 bpm
*''[[P waves]]'':  Upright, consistent, and normal in morphology (if no atrial disease)
|Regular
*''[[PR interval]]'':  Between 0.12–0.20 seconds and shortens with increasing heart rate
|Upright [[P waves]] precede each regular, narrow [[QRS]] complex
*''[[QRS complex]]'': Less than 0.12 seconds, consistent, and normal in morphology
|[[Short PR interval]]
*''Response to Maneuvers'':
|Less than 0.12 seconds, consistent, and normal in morphology
*''Epidemiology and Demographics'':
|Does often terminate with [[vagal maneuvers]] unlike [[sinus tachycardia]].
*''Pathophysiology'': *[[Sinus tachycardia]] is considered "appropriate" when a reasonable stimulus such as [[fever]], [[anemia]], fright, stress, or physical activity, provokes the tachycardia. This is in distinction to [[Inappropriate sinus tachycardia]] where no such stiumulus exists.
|-
 
|'''Wolff-Parkinson-White syndrome'''
===[[Ventricular Tachycardia]]===
|Estimated prevalence of WPW syndrome is 100 - 300 per 100,000 in the entire world.
*''Rate'':
|Atrial rate is nearly 300 bpm and ventricular rate is at 150 bpm.
*''Rhythm'': Generally regular
|Regular
*''[[P waves]]'': Normal morphology, upright, but dissociated from the QRS complex (i.e. "march through" the [[QRS complex]])
|[[P wave]] generally follows the [[QRS]] complex due to a bypass tract
*''[[PR interval]]'':
|Less than 0.12 seconds
*''[[QRS complex]]'': Wide and greater than 0.12 seconds
|[[Delta wave]] and evidence of ventricular pre-excitation if there is conduction to the ventricle via ante-grade conduction down an accessory pathway
*''Response to Maneuvers'': Does not terminate in response to [[adenosine]] or [[vagal maneuvers]]
|May break in response to [[procainamide]], [[adenosine]], [[vagal maneuvers]]
*''Epidemiology and Demographics'':
|}
*''Risk Factors:'': Occurs in the context of [[myocardial ischemia]], [[myocardial infarction]], [[congestive heart failure]], drug toxicity, and inhereted [[channelopathies]]
 
===[[Wolff-Parkinson-White syndrome]]===
*''Pathophysiology'': Anatomically and functionally, the fast and slow pathways of AVNRT should not be confused with the accessory pathways that give rise to [[Wolff-Parkinson-White syndrome]] ([[WPW]]) syndrome or [[AV reentrant tachycardia|atrioventricular re-entrant tachycardia]] ([[AVRT]]). In AVNRT, the fast and slow pathways are located within the [[right atrium]] in close proximity to or within the [[AV node]] and exhibit electrophysiologic properties similar to AV nodal tissue.  Accessory pathways that give rise to [[WPW]] syndrome and [[AVRT]] are located in the atrioventricular valvular rings, they provide a direct connection between the atria and ventricles, and have electrophysiologic properties similar to ventricular [[myocardium]].
*''Rate'':
*''Rhythm'':
*''[[P waves]]'': In WPW with orthodromic conduction due to a bypass tract, the [[p wave]] generally follows the [[QRS]] complex, whereas in [[AVNRT]], the [[p wave]] is generally buried in the [[QRS]] complex.
*''[[PR interval]]'':
*''[[QRS complex]]'': In WPW there is a [[delta wave]] and evidence of ventricular preexcitation if there is conduction to the ventrilce via antegrade conduction down an accessory pathway.  It should be noted, however, that in some patients with WPW, a delta wave and pre-excitation may not be present because bypass tracts do not conduct antegrade.
*''Response to Maneuvers'': May break in response to [[procainamide]], [[adenosine]], [[vagal maneuvers]]
*''Epidemiology and Demographics'':
*''Risk Factors'': None, an inhereted disorder


==References==
==References==
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[[Category:Intensive care medicine]]
[[Category:Intensive care medicine]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category: Overview complete]]
[[Category:Disease]]
[[Category:Needs overview]]


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Latest revision as of 00:45, 11 February 2020

Supraventricular tachycardia Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Among the Different Types of Supraventricular Tachycardia

Differentiating Supraventricular Tachycardia from Ventricular Tachycardia

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

EKG Examples

Chest X Ray

Echocardiography

Cardiac Catheterization

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

2015 ACC/AHA Guideline Recommendations

Acute Treatment of SVT of Unknown Mechanism
Ongoing Management of SVT of Unknown Mechanism
Ongoing Management of IST
Acute Treatment of Suspected Focal Atrial Tachycardia
Acute Treatment of Multifocal Atria Tachycardia
Ongoing Management of Multifocal Atrial Tachycardia
Acute Treatment of AVNRT
Ongoing Management of AVNRT
Acute Treatment of Orthodromic AVRT
Ongoing Management of Orthodromic AVRT
Asymptomatic Patients With Pre-Excitation
Management of Symptomatic Patients With Manifest Accessory Pathways
Acute Treatment of Atrial Flutter
Ongoing Management of Atrial Flutter
Acute Treatment of Junctional Tachycardia
Ongoing Management of Junctional Tachycardia
Acute Treatment of SVT in ACHD Patients
Ongoing Management of SVT in ACHD Patients
Acute Treatment of SVT in Pregnant Patients
Acute Treatment and Ongoing Management of SVT in Older Population

Prevention

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Case #1

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Differentiating Among the Different Types of Supraventricular Tachycardia

The individual subtypes of SVT can be distinguished from each other by certain physiological and electrical characteristics, many of which present in the patient's EKG. Supraventricular tachycardias must be differentiated from each other because the management strategies may vary:

Epidemiology Rate Rhythm P waves PR Interval QRS complex Response to maneuvers
Sinus Tachycardia Greater than 100 bpm Regular Upright, consistent, and normal in morphology 0.12–0.20 sec and shortens with high heart rate Less than 0.12 seconds, consistent, and normal in morphology May break with vagal maneuvers
Atrial Fibrillation More common in the elderly, following bypass surgery, in mitral valve disease, hyperthyroidism 110 to 180 bpm Irregularly irregular Absent, fibrillatory waves Absent Less than 0.12 seconds, consistent, and normal in morphology in the absence of aberrant conduction Does not break with adenosine or vagal maneuvers
Atrial Flutter More common in the elderly, after alcohol 75 (4:1 block), 100 (3:1 block) and 150 (2:1 block) bpm, but 150 is more common Regular Sawtooth pattern of P waves at 250 to 350 beats per minute Varies depending upon the magnitude of the block, but is short Less than 0.12 seconds, consistent, and normal in morphology Conduction may vary in response to drugs and maneuvers dropping the rate from 150 to 100 or to 75 bpm
AV Nodal Reentry Tachycardia (AVNRT) Accounts for 60%-70% of all SVTs. 80% to 90% of cases are due to antegrade conduction down a slow pathway and retrograde up a fast pathway. In adults the range is 140-250 bpm, but in children the rate can exceed 250 bpm Regular The P wave is usually superimposed on or buried within the QRS complex Cannot be calculated as the P wave is generally obscured by the QRS complex Less than 0.12 seconds, consistent, and normal in morphology May break with adenosine or vagal maneuvers
AV Reciprocating Tachycardia (AVRT) More common in males, whereas AVNRT is more common in females, occurs at a younger age. More rapid than AVNRT Regular A retrograde P wave is seen either at the end of the QRS complex or at the beginning of the ST segment Less than 0.12 seconds Less than 0.12 seconds, consistent, and normal in morphology May break with adenosine or vagal maneuvers
Inappropriate Sinus Tachycardia The disorder is uncommon. Most patients are in their late 20s to early 30s. More common in women. > 95 beats per minute. A nocturnal reduction in heart rate is present. There is an inappropriate heart rate response on exertion. Regular Normal morphology and precede the QRS complex Normal and < 0.20 seconds Less than 0.12 seconds, consistent, and normal in morphology Does not break with adenosine or vagal maneuvers
Junctional Tachycardia Common after heart surgery, digitalis toxicity, as an escape rhythm in AV block > 60 beats per minute Regular Usually inverted, may be burried in the QRS complex The P wave is usually buried in the QRS complex Less than 0.12 seconds, consistent, and normal in morphology Does not break with adenosine or vagal maneuvers
Multifocal Atrial Tachycardia (MAT) High incidence in the elderly and in those with COPD Atrial rate is > 100 beats per minute (bpm) Irregular P waves of varying morphology from at least three different foci Variable PR intervals, RR intervals, and PP intervals Less than 0.12 seconds, consistent, and normal in morphology Does not terminate with adenosine or vagal maneuvers
Sinus Node Reentry Tachycardia 100 to 150 bpm Regular Upright P waves precede each regular, narrow QRS complex Short PR interval Less than 0.12 seconds, consistent, and normal in morphology Does often terminate with vagal maneuvers unlike sinus tachycardia.
Wolff-Parkinson-White syndrome Estimated prevalence of WPW syndrome is 100 - 300 per 100,000 in the entire world. Atrial rate is nearly 300 bpm and ventricular rate is at 150 bpm. Regular P wave generally follows the QRS complex due to a bypass tract Less than 0.12 seconds Delta wave and evidence of ventricular pre-excitation if there is conduction to the ventricle via ante-grade conduction down an accessory pathway May break in response to procainamide, adenosine, vagal maneuvers

References


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