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Approach to a case of narrow complex tachycardia

narrow complex tachycardia is an important clinical cxondition to be known in acute medical care.......24/08/2011

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Approach to a case of narrow complex tachycardia

  1. 1. Approach to a patient<br />With <br />Narrow QRS complex <br />TACHYCARDIA<br />Dr.Nagula Praveen<br />24-08-2011<br />
  2. 2. My first CASE experience …<br /><ul><li>1.A 35 yr old female came to medicine OP with complaints of pounding sensation in the heart,dizziness.lightheadedness..the episode lasted for few minutes relieved spontaneously without any efforts..ending up in the patient passing urine after the absence of palpitations…on examination her heart heart was normal…there are no neck abnormalities…no other features..her BP is normal ..her thyroid status is normal ..What is the diagnosis was asked ?</li></li></ul><li>SUPRAVENTRICULAR<br />TACHYCARDIA<br />
  3. 3. CASE scenario<br /><ul><li>A 28 yr old woman has rapid palpitations accompanied by chest pain and dizziness while playing her cello.she is brought to an ED.she has a faint regular pulse of 180 bpm.her blood pressure is 100/70 mm Hg.cardiovascular signs reveals no signs of heart failure.an ECG show a regular tachycardia with a narrow QRS complex and no apparent Pwaves ..how should her case be managed?</li></li></ul><li>Clinically<br />Patient complains of recurrent palpitations,chestfullness,lightheadedness,presyncope,syncope.<br />Ppt factors may be present – exercise,caffeine,cigarettesmoking,alcohol.<br />h/o heart disease,pulmonarydisease,postAFablation.<br />CAUTION :H/O DIGOXIN USE <br />On examination– neck pounding –cannon waves “frog’s sign “ – practically pathognomic of AVNRT.<br />HR is a non specific feature in differentiating SVTs.<br />
  4. 4. STEP wise<br />Look for QRS duration.<br />QRS complex regular/irregular.<br />Then look for presence of p waves.<br />P waves morphology<br />P waves and QRS relationship 1:1<br />AV block present.<br />QRS alternation<br />Termination initiation of tachycardia.<br />Effect of BBB on tachycardia cycle length.<br />
  5. 5. Decision tree schema by BAR and colleagues <br />Ref–ncbl.org.in<br />
  6. 6.
  7. 7.
  8. 8. In brief from the diagram clues<br />Response to carotid sinus massage or adenosine –with termination of arrhythmia with Pwave –AVNRT with atrial premature beat .<br />Tachycardia persists with AV block –AT,AFL,SANRT<br />Pseudo r ‘ wave in V1 –AVNRT <br />SHORT RP interval – AVNRT,AVRT<br />Long RP interval – AT,SANRT,AVNRT atypical<br />
  9. 9.
  10. 10. ECG findings<br />
  11. 11. Main Mechanisms and Typical Electrocardiographic Recordings of Supraventricular Tachycardia.<br />
  12. 12.
  13. 13.
  14. 14.
  15. 15. Differentiation of <br />AVNRT<br /> from <br />AVRT<br />
  16. 16.
  17. 17. AVNRT<br />Presence of a narrow complex tachycardia with regular R-R intervals and no visible p waves.<br />P waves are retrograde and are inverted in leads II,III,AVF.<br />P waves are buried in the QRS complexes –simultaneous activation of atria and ventricles – most common presentation of AVNRT –66%.<br />If not synchronous –pseudo s wave in inferior leads ,pseudo r’ wave in lead V1---30% cases .<br />P wave may be farther away from QRS complex distorting the ST segment ---AVNRT ,mostly AVRT.<br />
  18. 18. AV NODAL REENTRANT TACHYCARDIA<br />
  19. 19.
  20. 20.
  21. 21. AFTER ADENOSINE<br />
  22. 22.
  23. 23.
  24. 24.
  25. 25. AVRT<br />Typical – RP interval < PR interval<br />RP interval > 80 milli sec<br />Atypical –RP interval > PR interval<br />Concealed bypass tract – only retrograde conduction<br />Manifest bypass tract– both anterograde and retrograde.<br />Electrical alternans –the amplitude of QRS complexes varies by 5 mm alternatively.<br />Rate related BBB occuring and the rate of tachycardia is decreasing –then the bypass tract is on the same side of the block.<br />
  26. 26. AV REENTRANT TACHYCARDIA<br />
  27. 27. PRinterval<br />PR interval<br />RP interval<br />
  28. 28.
  29. 29.
  30. 30. WPW syndrome<br />Two types<br />Orthodromic<br />Antidromic<br />Antidromic is wide complex tachycardia<br />In NSR detected by delta wave.<br />Can ppt into AF and VF on use of AV nodal blockers<br />MEMBRANE ACTIVE ANTIARRHTYHMIC DRUGS are safe.<br />CONCEALED WPW syndrome – no delta wave .less risk of AF<br />
  31. 31.
  32. 32.
  33. 33.
  34. 34. Orthodromic AVRT<br />
  35. 35. LOWN GANONG LEVINE syndrome<br />Short PR interval <br />Normal QRS complex<br />PSVT <br />
  36. 36. Sinus Tachycardia<br />
  37. 37. Focal Atrial Tachycardia<br />P wave morphology changes.<br />PR interval > 0.12 sec .<br />Second,third degree AV block can occur.<br />Tachycardia terminates with a qrs complex ..<br />Right atrial origin– p wave inverted in V1.<br />If biphasic in V1—initially positive then negative.<br />Upright in lead AVL <br />Opposite if of left atrial origin<br />Superior origin –upright p waves in inferior leads<br />Inferior origin –p waves are inverted in inferior leads.<br />
  38. 38.
  39. 39. Focal atrial tachycardia (LA focus)<br />
  40. 40. Multifocal Atrial Tachycardia<br />At least three consequtive p waves with different morphologies with a rate > 100 bpm to be present.<br />Isoelectric baseline between p waves.<br />Also called as choaticatrial tachycardia<br />Mostly seen in COPD ,electrolyte abn,theophylline<br />Rate usually does not exceed 130-140 bpm.<br />
  41. 41. Multifocal Atrial Tachycardia<br />
  42. 42. SANRT<br />Microreentrant tachycardia<br />Usually precipitated and terminated by premature atrial complexes.<br />Atrial rate is usually 120-150 bpm.<br />IART - Large or small reentrant circuit.<br />AV block can occur.<br />
  43. 43. Junctionaltachycardias<br />Non paroxysmal – accelerated junctional rhythm<br />Rate < 100 bpm Usually junctional node 40-60 bpm<br />Paroxysmal or focal junctional tachycardia is rare –automaticity.<br />110-250bpm.<br />P waves may be before or after QRS complex<br />Infrequent and nonsustained episodes –no treatment<br />Acute termination of SVT and establish the mechanism of SVT in case of acute setting.<br />Long term goal is abolishing the arryhthmia substrate.<br />Precipitating factors – electrolyte imbalance,hypoxia,ischemia,hyperthyroidism to be sought out.<br />
  44. 44. Acute Treatment <br />Of <br />SVT <br />
  45. 45. A 12 lead ECG during tachycardia and NSR.<br />No delay in therapy if the mechanism of SVT is not known.<br />Perform CAROTID SINUS MASSAGE,or give 6mg bolus adenosine.<br />In case of severe hemodynamic compromise a synchronisedcardioversion to be given.<br />
  46. 46. Carotid sinus massage<br />Check for carotid bruit before massage.<br />At the level of cricoidcartilage,at the angle of mandible the carotid sinus is situated.<br />Gentle pressure is applied over the carotid sinus for 5 -10 seconds.<br />ECG recording to be present.<br />In case of no response – try on the other side.<br />Simultaneous pressure not to be applied both sides.<br />Alternative manuevres are valsalva,gagreflex,ice water pouring over the face. <br />
  47. 47. If SVT is suspected to be AVnode dependent – drug of choice is adenosine and CCBs verapamil and diltiazem.<br />Useful for sustained cases of AV node independent tachycardias.<br />But digoxin,BBs,CCBs better control of ventricular response in atrialtachycardias<br />Class I agents to be combined with AV nodal blocking drugs – to eliminate 1:1 conduction of atrial to ventricles.<br />
  48. 48.
  49. 49.
  50. 50. Pharmacologic Agents for Short-Term Treatment of Supraventricular Tachycardia (SVT).<br />Delacrétaz E. N Engl J Med 2006;354:1039-1051.<br />
  51. 51. AFTER ADENOSINE<br />
  52. 52. Algorithm for <br />Short term management of SVT<br />
  53. 53. Algorithm for long term <br />Management of SVT<br />
  54. 54.
  55. 55.
  56. 56. Pill in the pocket approach<br /><ul><li>In whom recurrences are infrequent.
  57. 57. But sustained.well tolerated hemodynamically.
  58. 58. Patients who have had only a single episode of SVT..
  59. 59. 100-200mg of flecainide at the onset of SVT is a reasonable approach…until he reaches the hospital.
  60. 60. 40-160 mg verapamil –without preexcitation,
  61. 61. Betablockers
  62. 62. Propafenone 150-450 mg.
  63. 63. 80% cases interrupted with a combination of CCBand BB in 2 hrs…</li></li></ul><li>Long term control of SVT <br />Frequency and severity of episodes.<br />LVF<br />Cost benefits of radiofrequency ablation over the pharmacotherapy .<br />Pharmacotherapy is considered in patients who defer catheter ablation,whom in which ablation failed,or carries a risk of AV block.<br />Multifocal atrial tachycardia<br />Trial and error <br />Accessory pathway – class Ia,Ic,III<br />AV node blocking drugs<br />Young patients – Ia drugs<br />Class I agents LVD < 35% not used.<br />
  64. 64. Adenosine<br /><ul><li>not to be used in bronchospastic pulmonary disease.
  65. 65. Adenosine precipitates asthma
  66. 66. Given rapidly in 1-2 sec.
  67. 67. If given by peripheral vein uplift the arm..
  68. 68. Max dose is 30 mg
  69. 69. 6- 12-12 mg
  70. 70. Terminates AVNRT .AFL with 2:1 block
  71. 71. Potentiated by dipyradimole,carbamazepine –decrease dose to 3 mg. </li></li></ul><li>Other drugs<br /><ul><li>Calcium channel blockers,beta blockers ,digoxin are the next drugs to be used if not responded to adenosine
  72. 72. Usually 60 % cases respond to a dose of 6 mg and 95 % cases at 12 mg.
  73. 73. Type 1 a AAD, 1c,iii,AMIODARONE in refractory cases.
  74. 74. Beta blockers not to used IV in heart failure.
  75. 75. Long term treatment in case of recuurentepisodes,hemodynamic instability.</li></li></ul><li>Catheter guided Radiofrequency Ablation<br />Several multipolar catheters are introduced<br />High right atrium ,bundle of his ,RVapex,Coronary sinus.<br />Radiofrequency is delivered at the site of earlier activation <br />Success is defined by elimination of the tachycardia or loss of pre excitation.<br />90-98% success in AV node dependent <br />60-80% in case of AV node independent.<br />Cryoablation more useful…<br />
  76. 76. Catheter Ablation of Cardiac Arrhythmias.<br />
  77. 77. Pacemakers<br />Temporary role in case of digoxin toxicity.<br />Permanent in case of long term control <br />To terminate the tachycardia<br />Revert into sinus rhythm<br />Prevent the occurrence.<br />Overdrive suppression <br />RF induced atrial pacing are used<br />No role of surgery presently in PSVT rx .<br />
  78. 78.
  79. 79. Some important points <br />Rxof PSVT given for patient comfort except in IHD,MS<br />When the QRS complex is wide and VT is mistaken as SVT with ABERRANT conduction IV verapamil – not recommended decreases BP.<br />If DC cardioversion to be avoided because of possible adverse response to digitalis adm …pacing Rt atrium and ventricle via temp pacing.<br />In WPW syndrome avoid VERAPAMIL,LIDOCAINE .<br />Avoid digoxin.<br />In SANRT ,IART –class IA,IC ,BB <br />SANRT –digoxin.<br />
  80. 80. Cont…<br />Rx of ectopic atrial tachycardia – consider digitalis toxicity,chronic lung disease,metabolicabn,electrolyteabnormalities,acute MI ----temporary pacing.<br />Unsuccessful is EC<br />Removal or reversal of inciting factor<br />Surgical excision of focus.<br />Rx of MAT –chronic lung disease,metabolic,rare is digitlais toxicity ---CCBS,BBs ..no role of cardioversion,devices ,surgery.<br />
  81. 81. <ul><li>In case of WPW syndrome symptomatic concealed or manifested ..and evidence of preexcitation on NSR …send the patient for catheter ablation…</li></li></ul><li>Our case <br /><ul><li>1. carotid sinus pressure
  82. 82. 2.IV adenosine.
  83. 83. 3.long term treatment depends upon episodes.
  84. 84. 4.any underlying abnormality to be checked for.
  85. 85. 5.definitive etiology only knon by EP study.
  86. 86. 6.95% cases respond to RF ablation.
  87. 87. 7.much less complications with cryoablation.
  88. 88. 8.in case if SVT recurrs after ablation –opt for pacemaker..</li></li></ul><li>Lets have a look at the ECGs<br />
  89. 89. SUPRAVENTRICULAR TACHYCARDIAS<br />“You only get so many heart beats – you should save some for later in life” Dr. Samuel Levine<br />
  90. 90.
  91. 91.
  92. 92.
  93. 93. DIAGNOSIS IS ATRIAL FLUTTER<br />
  94. 94. Sinus tachycardia was thought..<br />but it was AFL<br />
  95. 95.
  96. 96. AVNRT in structural heart disease<br />
  97. 97. Look for the correct lead placement<br />
  98. 98. AVNRT can occur in the background of acute MI<br />
  99. 99.
  100. 100.
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  102. 102.
  103. 103.
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  106. 106.
  107. 107.
  108. 108. Special problems<br />1.Coexisting Double Tachycardias<br />May not be identified during noninvasive testing ..needs EP study.<br />Ex—typical AVNRT and AT.<br />Concentric –eccentric –concentric.<br />AVNRT –both APC,VPC <br />AT only APC<br />2.Pseudo AF- infrequent presentation of PSVT.<br />Occurs during onset and termination of tahcycardia.<br />Multiple accessory AV pathways.<br />In young who have AF without other risk factors.<br />5% of AVNRT.<br />Group beating is seen <br />
  109. 109. REFERENCES<br /><ul><li>CARDIOLOGY third edition –Michael. H.Crawford
  110. 110. HURST’S THE HEART – 12 th edition.
  111. 111. BRAUNWALD’S HEART DISEASE –A TEXTBOOK OF CARDIOVASCULAR MEDICINE – 7 th ED
  112. 112. HARRISON’S PRINICPLES OF INTERNAL MEDICINE -17 th ED
  113. 113. SUPRAVENTRICULAR TACHYCARDIA –NEJM 2006
  114. 114. CARDIOVASCULAR MEDICINE – SVT – JERONIMO FERRE’
  115. 115. BASIC AND BEDSIDE ELECTROCARDIOGRAPHY –ROMULO.F.BALTAZAR
  116. 116. SCHAMROTH –ELECTROCARDIOGRAPHY
  117. 117. www.medscape.com
  118. 118. www.ecglibrary.com
  119. 119. www.googleimages.com
  120. 120. www.acc.org.
  121. 121. www.clinicaltrials.gov
  122. 122. www.nejm.org</li></li></ul><li>
  123. 123. Aim for any case of cardiology <br />
  124. 124. Thank you<br />Sagittarian<br />

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