Narrow complex tachycardia resident survival guide: Difference between revisions
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{{familytree | | | | | | | | C01 | | | | | | | |C01=<div style="float: left; text-align: left; height: em; width: 22em; padding:1em;">'''Order tests'''<br> | {{familytree | | | | | | | | C01 | | | | | | | |C01=<div style="float: left; text-align: left; height: em; width: 22em; padding:1em;">'''Order tests'''<br> | ||
❑ [[ECG]]<br>❑ [[Echocardiography]] (in patients with sustained [[SVT]])†<br>❑ 24 hour [[holter monitor]] (in patients with frequent but transient tachycardias)<br> ❑ Loop recorder (in patients with less frequent arrhythmias)<br>❑ Trans-esophageal atrial recordings (if other investigations have failed to document an arrhythmia)</div>}} | ❑ [[ECG]]<br>❑ [[Echocardiography]] (in patients with sustained [[SVT]])†<br>❑ 24 hour [[holter monitor]] (in patients with frequent but transient tachycardias)<br> ❑ Loop recorder (in patients with less frequent arrhythmias)<br>❑ Trans-esophageal atrial recordings (if other investigations have failed to document an arrhythmia)</div>}} | ||
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{{familytree | | | | | D01 | | | | D02 | | | | | |D01='''Arrhythmia undocumented'''|D02='''Arrhythmia documented'''}} | {{familytree | | | | | D01 | | | | | D02 | | | | | |D01='''Arrhythmia undocumented'''|D02='''Arrhythmia documented'''}} | ||
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{{familytree | | | E01 | | E02 | | E03 | | | {{familytree | | | E01 | | E02 | | E03 | | E04 | |E01=<div style="float: left; text-align: left; height: 5em; width: 12em; padding:1em;"> ❑ History suggests extra premature beats.<br>❑ [[Surface ECG]] is normal.</div> |E02=<div style="float: left; text-align: left; height: em; width: 12em; padding:1em;"> ❑ History suggests paroxysmal arrhythmia.<br> ❑ [[12 lead ECG]] doesn't suggest any mechanism for arrhythmia.</div> |E03=<div style="float: left; text-align: left; height: em; width: 12em; padding:1em;">'''Stable patient'''</div>|E04=<div style="float: left; text-align: left; height: em; width: 12em; padding:1em;">'''Unstable patient'''</div>}} | ||
{{familytree | | | |!| | | |!| | | | | | | | | | | }} | {{familytree | | | |!| | | |!| | | |!| | | |!| | | }} | ||
{{familytree | | | F01 | | F02 | | | | | {{familytree | | | F01 | | F02 | | F03 | | F04 | |F01=<div style="float: left; text-align: left; height: em; width: 12em; padding:1em;"> Rule out following:<br> | ||
❑ [[Caffeine]]<br>❑ [[Alcohol]]<br>❑ [[Nicotine]]<br>❑ [[Recreational drugs]]<br>❑ [[Hyperthyroidism]]</div>|F02=<div style="float: left; text-align: left; height: em; width: 16em; padding:1em;">❑ Refer for an invasive electrophysiological study AND/OR<br>❑ [[Catheter ablation]]<br> ❑ Teach [[vagal maneuvers]] to patients.<br> ❑ Consider beta blocking agent.</div>}} | ❑ [[Caffeine]]<br>❑ [[Alcohol]]<br>❑ [[Nicotine]]<br>❑ [[Recreational drugs]]<br>❑ [[Hyperthyroidism]]</div>|F02=<div style="float: left; text-align: left; height: em; width: 16em; padding:1em;">❑ Refer for an invasive electrophysiological study AND/OR<br>❑ [[Catheter ablation]]<br> ❑ Teach [[vagal maneuvers]] to patients.<br> ❑ Consider beta blocking agent.</div>|F03=<div style="float: left; text-align: left; height: em; width: 12em; padding:1em;">❑ Treat according to the type of arrhythmia.</div>|F04=<div style="float: left; text-align: left; height: em; width: 12em; padding:1em;">❑ Obtain a monitor strip form the defibrillator.<br>❑ Immediate direct current [[cardioversion]].</div>}} | ||
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== Management== | == Management== | ||
'''Figure 1: Differential diagnosis for narrow QRS tachycardia.'''<ref name="circ.ahajournals.org">{{Cite web | last = | first = | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher = | date = | accessdate = 15 August 2013 }}</ref> | '''Figure 1: Differential diagnosis for narrow QRS tachycardia.'''<ref name="circ.ahajournals.org">{{Cite web | last = | first = | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher = | date = | accessdate = 15 August 2013 }}</ref> | ||
Revision as of 20:56, 2 March 2014
| File:Critical Pathways.gif |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hilda Mahmoudi M.D., M.P.H.[2]
Definition
Narrow complex tachycardia is defined as a rhythm with heart rate > 100 beats per minute and a QRS complex duration < 120 milliseconds.
Causes
Life Threatening Causes
Life-threatening causes include conditions which result in death or permanent disability within 24 hours if left untreated.
Common Causes
Initial Diagnosis
| Charcterize the symptoms | |||||||||||||||||||||||||||||||||||||||
| Examine the patient | |||||||||||||||||||||||||||||||||||||||
Order tests ❑ ECG ❑ Echocardiography (in patients with sustained SVT)† ❑ 24 hour holter monitor (in patients with frequent but transient tachycardias) ❑ Loop recorder (in patients with less frequent arrhythmias) ❑ Trans-esophageal atrial recordings (if other investigations have failed to document an arrhythmia) | |||||||||||||||||||||||||||||||||||||||
| Arrhythmia undocumented | Arrhythmia documented | ||||||||||||||||||||||||||||||||||||||
❑ History suggests extra premature beats. ❑ Surface ECG is normal. | ❑ History suggests paroxysmal arrhythmia. ❑ 12 lead ECG doesn't suggest any mechanism for arrhythmia. | Stable patient | Unstable patient | ||||||||||||||||||||||||||||||||||||
❑ Refer for an invasive electrophysiological study AND/OR ❑ Catheter ablation ❑ Teach vagal maneuvers to patients. ❑ Consider beta blocking agent. | ❑ Treat according to the type of arrhythmia. | ❑ Obtain a monitor strip form the defibrillator. ❑ Immediate direct current cardioversion. | |||||||||||||||||||||||||||||||||||||
Management
Figure 1: Differential diagnosis for narrow QRS tachycardia.[1]
| Narrow QRS tachycardia (QRS duration less than 120 ms) | |||||||||||||||||||||||||||||||||||||||||||
| Regular rhythm | Irregular rhythm | ||||||||||||||||||||||||||||||||||||||||||
| Visible P waves? | Atrial fibrillation Atrial tachycardia/flutter with variable AV conduction MAT | ||||||||||||||||||||||||||||||||||||||||||
| No | Yes | ||||||||||||||||||||||||||||||||||||||||||
| Atrial rate greater than ventricular rate? | |||||||||||||||||||||||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||||||||||||||||||||||
| Atrial flutter or atrial tachycardia | Analyze RP interval | ||||||||||||||||||||||||||||||||||||||||||
| Short (RP shorter than PR) | Long (RP longer than PR) | ||||||||||||||||||||||||||||||||||||||||||
| RP shorter than 70 ms | RP longer than 70 ms | Atrial tachycardia PJRT Atypical AVNRT | |||||||||||||||||||||||||||||||||||||||||
| AVNRT | AVRT AVNRT Atrial tachycardia | ||||||||||||||||||||||||||||||||||||||||||
† Echocardiographic examination is required in patients with documented sustained supraventricular tachycardia to rule out structural heart disease.
Patients with focal junctional tachycardia may mimic the pattern of slow-fast AVNRT and may show AV dissociation and/or marked irregularity in the junctional rate.
AV indicates atrioventricular; AVNRT, atrioventricular nodal reciprocating tachycardia; MAT, multifocal atrial tachycardia; ms, miliseconds; PJRT, permanent form of junctional reciprocating tachycardia; QRS, ventricular activation on ECG.
Algorithm based on the 2003 ACC/AHA/ESC guidelines for the management of supraventricular arrhythmias.[1]
Figure 2: Acute management of patients with hemodynamically stable and narrow QRS regular tachycadia:[1]
| Hemodynamically stable regular tachycardia | |||||||||||||||||||||||||||||||||||||||||||
| Narrow QRS | |||||||||||||||||||||||||||||||||||||||||||
| SVT | |||||||||||||||||||||||||||||||||||||||||||
| Vagal maneuvers IV adenosine† IV verapamil/diltiazem IV beta blocker | |||||||||||||||||||||||||||||||||||||||||||
| Termination | |||||||||||||||||||||||||||||||||||||||||||
| Yes | No,persistent tachycardia with AV block | ||||||||||||||||||||||||||||||||||||||||||
| *IV ibutilide plus AV-nodal-blocking agent Overdrive pacing/DC cardioversion, and/or rate control | |||||||||||||||||||||||||||||||||||||||||||
†Adenosine should be used with caution in patients with severe coronary artery disease and may produce
AF, which may result in rapid ventricular rates for patients with pre-excitation. *Ibutilide is especially effective for patients with atrial flutter but should not be used in patients with EF less than 30% due to increased risk of polymorphic VT. AF indicates atrial fibrillation; AV, atrioventricular; BBB, bundle-branch block; DC, direct current; IV, intravenous; LV, left ventricle; QRS, ventricular activation on ECG; SVT, supraventricular tachycardia; VT, ventricular tachycardia.
Algorithm based on the 2003 ACC/AHA/ESC guidelines for the management of supraventricular arrhythmias.[1]
Figure 3: Responses of narrow complex tachycardias to adenosine.[1]
| Regular narrow QRS complex tachycardia | |||||||||||||||||||||||||||||||||||||||||||||||
| IV adenosine | |||||||||||||||||||||||||||||||||||||||||||||||
| No change in rate | Gradual slowing then reacceleration of rate | Sudden termination | Persisting atrial tachycardia with transient high-grade AV block | ||||||||||||||||||||||||||||||||||||||||||||
| Inadequate dose/delivery Condiser VT (fascicular or hight septal origin) | Sinus tachycardia Focal AT Nonparoxysmal junctional tachycardia | AVNRT AVRT Sinus node re-entry Focal AT | Atrial flutter AT | ||||||||||||||||||||||||||||||||||||||||||||
AT indicates atrial tachycardia; AV, atrioventricular; AVNRT, atrioventricular nodal reciprocating tachycardia; AVRT, atrioventricular reciprocating tachycardia; IV, intravenous; QRS, ventricular activation on ECG; VT, ventricular tachycardia.
Algorithm based on the 2003 ACC/AHA/ESC guidelines for the management of supraventricular arrhythmias.[1]
Do's
- Refer narrow complex tachycardic patients with following characteristics to a cardiac arrhythmia specialist:
- Patients with drug resistance
- Patients with intolerance to drugs
- Patients who do not want any drug therapy.
- Patients with severe symptoms such as syncope and dyspnoea during palpitations.
- Refer all the patients with Wolff-Parkinson-White syndrome (WPW syndrome) to a cardiac arrhythmia specialist.
Don'ts
- Do not perform esophageal stimulation if an invasive electrophysiological investigation is planned.