Supraventricular tachycardia differential diagnosis: Difference between revisions

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==Differentiating Among the Different Types of Supraventricular Tachycardia==
==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.
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:
 
{| class="wikitable"
[[Supraventricular tachycardias]] must be differentiated from each other because the management strategies may vary:
|+
 
!
===[[Atrial Fibrillation]]===
!Epidemiology
*''Rate'': 110 to 180 bpm
!Rate
*''Rhythm'': Irregularly irregular
!Rhythm
*''[[P waves]]'': Absent, fibrillatory waves
!P waves
*''[[PR interval]]'': Absent
!PR Interval
*''[[QRS complex]]'': Less than 0.12 seconds, consistent, and normal in morphology in the absence of aberrant conduction
!QRS complex
*''Response to Maneuvers'': Does not break with [[adenosine]] or [[vagal maneuvers]]
!Response to maneuvers
*''Epidemiology and Demographics'':  More common in the elderly, following [[bypass surgery]], in mitral valve disease, [[hyperthyroidism]]
|-
 
|'''Sinus Tachycardia'''
===[[Atrial Flutter]]===
|
*''Rate'': 75 (4:1 block), 100 (3:1 block) and 150 (2:1 block) bpm, but 150 is most common
|Greater than 100 bpm
*''Rhythm'': Regular
|Regular
*''[[P waves]]'': Sawtooth pattern of [[P waves]] at 250 to 350 beats per minute
|Upright, consistent, and normal in morphology
*''[[PR interval]]'': Varies depending upon the magnitude of the block, but is short
|0.12–0.20 sec and shortens with high heart rate
*''[[QRS complex]]'': Less than 0.12 seconds, consistent, and normal in morphology
|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
|May break with [[vagal maneuvers]]
*''Epidemiology and Demographics'': More common in the elderly, after alcohol
|-
 
|'''Atrial Fibrillation'''
===[[AV Nodal Reentry Tachycardia]] ([[AVNRT]])===
|More common in the elderly, following [[bypass surgery]], in mitral valve disease, [[hyperthyroidism]]
*''Rate'':  In adults the range is 140-250 bpm, but in children the rate can exceed 250 bpm.
|110 to 180 bpm
*''Rhythm'': Regular
|Irregularly irregular
*''[[P waves]]'': The [[P wave]] is usually superimposed on or buried within the [[QRS complex]]
|Absent, fibrillatory waves
*''[[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]].
|Absent
*''[[QRS complex]]'': Less than 0.12 seconds, consistent, and normal in morphology in the absence of aberrant conduction, [[QRS alternans]] may be present
|Less than 0.12 seconds, consistent, and normal in morphology in the absence of aberrant conduction
*''Response to Maneuvers'': May break with [[adenosine]] or [[vagal maneuvers]]
|Does not break with [[adenosine]] or [[vagal maneuvers]]
*''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.
|-
 
|'''Atrial Flutter'''
===[[AV Reciprocating Tachycardia]] ([[AVRT]])===
|More common in the elderly, after alcohol
*''Rate'': More rapid than AVNRT
|75 (4:1 block), 100 (3:1 block) and 150 (2:1 block) bpm, but 150 is more common
*''Rhythm'': Regular
|Regular
*''[[P waves]]'': Due to retrograde conduction a retrograde P wave is seen either at the end of the QRS complex or at the beginning of the ST segment.
|Sawtooth pattern of [[P waves]] at 250 to 350 beats per minute
*''[[PR interval]]'': Less than 0.12 seconds
|Varies depending upon the magnitude of the block, but is short
*''[[QRS complex]]'': Less than 0.12 seconds, consistent, and normal in morphology
|Less than 0.12 seconds, consistent, and normal in morphology
*''Response to Maneuvers'': May break with [[adenosine]] or [[vagal maneuvers]]
|Conduction may vary in response to drugs and maneuvers dropping the rate from 150 to 100 or to 75 bpm
*''Epidemiology and Demographics'': More common in males, whereas AVNRT is more common in females, occurs at a younger age.
|-
*''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.
|'''AV Nodal Reentry Tachycardia (AVNRT)'''
**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. 
|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 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 outside of the bundle of His, the QRS complex in antidromic AVRT is often wider than usual, with a [[delta wave]].
|In adults the range is 140-250 bpm, but in children the rate can exceed 250 bpm
 
|Regular
===[[Inappropriate Sinus Tachycardia]]===
|The [[P wave]] is usually superimposed on or buried within the [[QRS complex]]
*''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.
|Cannot be calculated as the P wave is generally obscured by the [[QRS complex]]
*''Rhythm'': Regular
|Less than 0.12 seconds, consistent, and normal in morphology
*''[[P waves]]'': Normal morphology and precede the [[QRS complex]]
|May break with [[adenosine]] or [[vagal maneuvers]]
*''[[PR interval]]'': Normal and < 0.20 seconds
|-
*''[[QRS complex]]'': Less than 0.12 seconds, consistent, and normal in morphology
|'''AV Reciprocating Tachycardia (AVRT)'''
*''Response to Maneuvers'': Does not break with [[adenosine]] or [[vagal maneuvers]]
|More common in males, whereas AVNRT is more common in females, occurs at a younger age.
*''Epidemiology and Demographics'': The disorder is uncommon. Most patients are in their late 20s to early 30s. More common in women.
|More rapid than AVNRT
*''Pathophysiology'': These patients have no apparent heart disease or other causes of sinus tachycardia. IST is thought to be due to abnormal autonomic control.
|Regular
 
|A retrograde P wave is seen either at the end of the QRS complex or at the beginning of the ST segment
===[[Junctional Tachycardia]]===
|Less than 0.12 seconds
*''Rate'': > 60 beats per minute
|Less than 0.12 seconds, consistent, and normal in morphology
*''Rhythm'': Regular
|May break with [[adenosine]] or [[vagal maneuvers]]
*''[[P waves]]'': Usually inverted, may be burried in the QRS complex
|-
*''[[PR interval]]'': The [[p wave]] is usually buried in the [[QRS complex]]
|'''Inappropriate Sinus Tachycardia'''
*''[[QRS complex]]'': Less than 0.12 seconds, consistent, and normal in morphology
|The disorder is uncommon. Most patients are in their late 20s to early 30s. More common in women.
*''Response to Maneuvers'': Does not break with [[adenosine]] or [[vagal maneuvers]]
|> 95 beats per minute. A nocturnal reduction in heart rate is present. There is an inappropriate heart rate response on exertion.
*''Epidemiology and Demographics'': Common after [[heart surgery]], [[digitalis toxicity]], as an escape rhythm in [[AV block]]
|Regular
 
|Normal morphology and precede the [[QRS complex]]
===[[Multifocal Atrial Tachycardia]]===
|Normal and < 0.20 seconds
 
|Less than 0.12 seconds, consistent, and normal in morphology
*''Rate'': Atrial rate is > 100 beats per minute (bpm)
|Does not break with [[adenosine]] or [[vagal maneuvers]]
*''Rhythm'': Irregular
|-
*''[[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
|'''Junctional Tachycardia'''
*''[[PR interval]]'': Variable [[PR interval]]s, [[RR interval]]s, and [[PP interval]]s
|Common after [[heart surgery]], [[digitalis toxicity]], as an escape rhythm in [[AV block]]
*''[[QRS complex]]'': Less than 0.12 seconds, consistent, and normal in morphology
|> 60 beats per minute
*''Response to Maneuvers'': Does not terminate with [[adenosine]] or [[vagal maneuvers]]
|Regular
*''Epidemiology and Demographics'': High incidence in the elderly and in those with [[COPD]]
|Usually inverted, may be burried in the QRS complex
 
|The [[P wave]] is usually buried in the [[QRS complex]]
===[[Sinus Node Reentry Tachycardia]]===
|Less than 0.12 seconds, consistent, and normal in morphology
*''Rate'': 100 to 150 bpm
|Does not break with [[adenosine]] or [[vagal maneuvers]]
*''Rhythm'': Regular
|-
*''[[P waves]]'': Upright [[P waves]] precede each regular, narrow [[QRS]] complex
|'''Multifocal Atrial Tachycardia (MAT)'''
*''[[PR interval]]'': Short PR interval
|High incidence in the elderly and in those with [[COPD]]
*''[[QRS complex]]'': Less than 0.12 seconds, consistent, and normal in morphology
|Atrial rate is > 100 beats per minute (bpm)
*''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]].
|Irregular
 
|P waves of varying morphology from at least three different foci
===[[Sinus Tachycardia]]===
|Variable [[PR interval]]s, [[RR interval]]s, and [[PP interval]]s
*''Rate'': Greater than 100
|Less than 0.12 seconds, consistent, and normal in morphology
*''Rhythm'': Regular
|Does not terminate with [[adenosine]] or [[vagal maneuvers]]
*''[[P waves]]'': Upright, consistent, and normal in morphology (if no atrial disease)
|-
*''[[PR interval]]'': Between 0.12–0.20 seconds and shortens with increasing heart rate
|'''Sinus Node Reentry Tachycardia'''
*''[[QRS complex]]'': Less than 0.12 seconds, consistent, and normal in morphology
|
*''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|"inappropriate" sinus tachycardia]] where no such stimulus exists.
|100 to 150 bpm
 
|Regular
===[[Wolff-Parkinson-White syndrome]]===
|Upright [[P waves]] precede each regular, narrow [[QRS]] complex
*''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]].
|[[Short PR interval]]
*''Rate'': Atrial rate is nearly 300 bpm and ventricular rate is at 150 bpm.
|Less than 0.12 seconds, consistent, and normal in morphology
*''Rhythm'': Regular
|Does often terminate with [[vagal maneuvers]] unlike [[sinus tachycardia]].
*''[[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]]'': Less than 0.12 seconds
|'''Wolff-Parkinson-White syndrome'''
*''[[QRS complex]]'': In WPW there is a [[delta wave]] and evidence of ventricular pre-excitation if there is conduction to the ventricle via ante-grade 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 ante-grade.
|Estimated prevalence of WPW syndrome is 100 - 300 per 100,000 in the entire world.
*''Response to Maneuvers'': May break in response to [[procainamide]], [[adenosine]], [[vagal maneuvers]]
|Atrial rate is nearly 300 bpm and ventricular rate is at 150 bpm.
*''Epidemiology and Demographics'': Estimated prevalence of WPW syndrome is 100 - 300 per 100,000 in the entire world.
|Regular
*''Risk Factors'': None, an inherited disorder
|[[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==
==References==

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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