Narrow complex tachycardia resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hilda Mahmoudi M.D., M.P.H.[2]; Twinkle Singh, M.B.B.S. [3]; Rim Halaby, M.D. [4]; Amr Marawan, M.D. [5]

Narrow Complex Tachycardia Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Initial
Specific
Do's
Don'ts

Overview

Narrow complex tachycardia is characterized by a heart rate > 100 beats per minute and a QRS complex of a duration < 120 milliseconds. Narrow complex tachycardia may originate in the sinus node, atria, AV node, bundle of His, or a combination of these tissues. The diagnosis of narrow complex tachycardia is based on the ECG findings. Hemodynamically unstable patients should receive urgent synchronized cardioversion.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Boxes in the red color signify that an urgent management is needed.

 
 
 
 
 
 
Identify cardinal findings that increase the pretest probability of narrow complex tachycardia
Palpitations
Heart rate > 100 beats/min
QRS complex < 120 ms

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the following findings that require urgent cardioversion?

❑ Hemodynamic instability

Hypotension
Cold extremities
Peripheral cyanosis
Mottling
Altered mental status

Chest discomfort suggestive of ischemia

Decompensated heart failure[1]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Urgent synchronized cardioversion
❑ Narrow regular rhythm: 50-100 Joules
❑ Narrow irregular rhythm: 120-200 Joules biphasic or 200 Joules monophasic[1][2]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[2]
Abbreviations: ECG: electrocardiogram; SVT: Supraventricular tachycardia; ms: milliseconds; AV: atrioventricular; AVNRT: atrioventricular nodal reciprocating tachycardia; MAT: multifocal atrial tachycardia; ms: milliseconds; PJRT: permanent form of junctional reciprocating tachycardia; RP interval: is the time between anterograde ventricular activation (R wave) and retrograde atrial activation (P wave)

 
 
 
 
 
 
 
Characterize the symptoms:

❑ Asymptomatic (most common presentation)
Palpitations
❑ Sensation of a pause followed by a strong heart beat (suggestive of premature beats)
Dyspnea
Fatigue
Chest discomfort
Lightheadedness
Syncope
Polyuria
Characterize the timing of the symptoms:
❑ Onset

❑ First episode
❑ Recurrent

❑ Duration
❑ Frequency
❑ Termination of the episode

❑ Spontaneous
❑ Medication use
❑ Not terminated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Examine the patient:
Vitals
Pulse

❑ Rate
Tachycardia
❑ Rhythm
❑ Regular
❑ Irregular (atrial fibrillation, MAT)
❑ Strength
❑ Weak
❑ Alternating in strength (atrial fibrillation)

Respiration

Tachypnea

Blood pressure

Normal (typical)
Hypotension (in hemodynamically unstable patients)

Neck

❑ Absent a wave in jugular venous pressure (in atrial fibrillation)

Cardiovascular examination
❑ Auscultation

Heart sounds
❑ Rapid regular or irregular beats
❑ Murmurs (suggestive of valvular diseases)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ Order and monitor the ECG
Perform urgent cardioversion in unstable patients

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Narrow QRS tachycardia
Heart rate > 100 beats/min
QRS complex < 120 ms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Determine the regularity of the rhythm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Regular rhythm
 
 
 
 
 
 
 
Irregular rhythm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider the following causes:

AVRT
AVNRT
Atypical AVNRT
Atrial tachycardia

Atrial flutter
 
 
 
 
 
 
 
Consider the following causes:

Atrial fibrillation
Atrial tachycardia/flutter with variable AV conduction

MAT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine P wave morphology
 
 
 
 
 
 
 
Determine P wave morphology
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
P waves are not visible
 
P waves are visible
 
❑ > 3 P wave morphologies
 
❑ Absent P waves
 
❑ Sawtooth appearance of P waves
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Consider AVNRT
 
Determine if atrial rate is greater than ventricular rate
 
❑ Consider MAT
 
❑ Consider atrial fibrillation
 
❑ Consider atrial flutter
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Atrial rate > ventricular rate
 
Atrial rate ≤ ventricular rate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider the following causes:
Atrial flutter
Atrial tachycardia
 
❑ Determine if RP interval > PR interval
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
RP < PR
 
 
 
RP > PR
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine the duration of RP interval
 
 
 
Consider the following causes:

Atrial tachycardia
❑ PJRT

Atypical AVNRT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
< 70 ms
 
> 70 ms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider the following cause:
AVNRT
 
Consider the following causes:
AVRT
AVNRT
Atrial tachycardia
 
 
 
 
 
 
 
 
 


ECG Examples

Shown below is a table depicting the ECG findings of the different types of narrow complex tachycardia.[3][4]

Type of Arrhythmia EKG (lead II)† Clues
Sinus tachycardia Sinus tachycardia.png Onset and termination: gradual
Rhythm: regular
Rate: >220 minus the age of the patient
Response to adenosine: transient decrease of the rate
Atrial fibrillation Atrial fibrillation.png Onset and termination: abrupt
Rhythm: irregular
Rate:100-180 bpm
Response to adenosine: transient decrease of the ventricular rate
Atrial flutter Atrial flutter.png Onset and termination: abrupt
Rhythm: regular
Rate: >150 bpm
Response to adenosine: transient decrease of the rate
Presence of saw-tooth appearance
AVNRT AVNRT.png Onset and termination: abrupt
Rhythm: regular
Rate: 150-250 bpm
Response to adenosine: termination of the arrhythmia
AVRT AVRT.png Onset and termination: abrupt
Rhythm: regular
Rate: 150-250 bpm
Response to adenosine: termination of the arrhythmia
Focal atrial tachycardia Focal atrial tachycardia.png Onset and termination: abrupt
Rhythm: regular
Rate: 150-250 bpm
Nonparoxysmal junctional tachycardia JTS.png Rhythm: regular
Retrograde P wave
Most commonly due to ischemia or digitalis toxicity
Multifocal atrial tachycardia MAT.png Onset and termination: gradual
Rhythm: irregular
Rate: 100-150 bpm
Response to adenosine: no effect
3 different P wave morphologies

ECG strips are courtesy of ECGpedia.

Treatment

Initial Treatment

Shown below is an algorithm summarizing the management of narrow complex tachycardia according to the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias.[2]
Abbreviations: AF: atrial fibrillation; AV: atrioventricular; AVNRT: atrioventricular nodal reciprocating tachycardia; AVRT: atrioventricular reciprocating tachycardia; BBB: bundle-branch block; ECG: electrocardiography; IV: intravenous; LV: left ventricle; SVT: supraventricular tachycardia; VT: ventricular tachycardia

 
 
Does the patient have any of the following findings that require urgent cardioversion?

❑ Hemodynamic instability

Hypotension
Cold extremities
Peripheral cyanosis
Mottling
Altered mental status

Chest discomfort suggestive of ischemia

Decompensated heart failure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
Urgent synchronized cardioversion

❑ Narrow regular rhythm: 50-100 J

❑ Narrow irregular rhythm: 120-200 J biphasic or 200 J monophasic
 
Acute management:

❑ Perform vagal maneuvers (Class I, level of evidence B)

Valsalva maneuver
Carotid sinus massage

Carotid massage is contraindicated in case of prior MI, transient ischemic attack or stroke within the last three months, previous history of ventricular fibrillation or fibrillation tachycardia, and in case of carotid bruits.[5]

❑ Monitor ECG continuously
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If vagal maneuvers fail:

❑ Administer IV adenosine (Class I, level of evidence A)

❑ First dose: 6 mg rapid IV push, followed by 20 mL of normal saline bolus
❑ Second dose: 12 mg (if no response in 1-2 min)

Adenosine is contraindicated in cardiac transplant patients. Use adenosine with caution in severe obstructive lung disease.[3]

❑ Monitor ECG continuously
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If adenosine fails, administer ONE of the following:

❑ IV verapamil 5 mg IV every 3-5 min, maximum 15 mg (Class I, level of evidence A)[3]
❑ IV diltiazem (Class I, level of evidence A)

❑ 0.25 mg/kg over 2 minutes
❑ Additional 0.35 mg/kg over 2 minutes
❑ Maintenance infusion of 5-15 mg/hour[3]

❑ IV beta blocker (Class IIb, level of evidence C)

Metoprolol
❑ 5 mg over 2 minutes
❑ Up to 3 doses within 15 minutes
Esmolol
❑ 250-500 μg/kg over 1 minute
❑ Maintenance with 50-200 μg/kg over 4 minutes (if needed)
Propranolol
❑ 0.15 mg/kg over 2 minutes[3]

❑ Monitor ECG continuously
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Arrhythmia is terminated
 
Arrhythmia is persistent
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No further therapy is required if:
❑ Patient is stable
LV function is normal
❑ Normal sinus rhythm on ECG
 
❑ Administer AV-nodal-blocking agent AND one of the following
❑ IV ibutilide

Ibutilide is especially indicated for patients with atrial flutter but should not be used in patients with ejection fraction less than 30% as it increases risk of polymorphic VT.

❑ 1 mg over 10 minutes (if ≥ 60 kg)
❑ 0.01 mg/kg over 10 minutes (if <60 kg)
❑ Repeat once after 10 minutes if needed
❑ IV procainamide
❑ 30 mg/min infusion, maximum 17 mg/kg
❑ Maintenance 2-4 mg/min
❑ IV flecainide 2mg/kg over 10 min[3]

OR

❑ DC cardioversion
 

Treatment of Specific Supraventricular Arrhythmia

Focal Atrial Tachycardia

Management of focal atrial tachycardia
Acute treatment
Conversion in hemodynamically unstable patient DC cardioversion (Class I, level of evidence B)
Conversion in hemodynamically stable patient Adenosine (Class IIa, level of evidence C)
OR
Verapamil (Class IIa, level of evidence C)
OR
Diltiazem (Class IIa, level of evidence C)
OR
Beta blocker (Class IIa, level of evidence C)
OR
Amiodarone (Class IIa, level of evidence C)
OR
Sotalol (Class IIa, level of evidence C)
OR
Procainamide (Class IIa, level of evidence C)
OR
Flecainide (Class IIa, level of evidence C)
OR
Propafenone (Class IIa, level of evidence C)
Rate control Verapamil (Class I, level of evidence C)
OR
Diltiazem (Class I, level of evidence C)
OR
Beta blocker (Class I, level of evidence C)
OR
Digoxin (Class IIb, level of evidence C)
Prophylactic therapy
Recurrent symptomatic atrial tachycardia Catheter ablation (Class I, level of evidence B)
OR
Beta blockers (Class I, level of evidence C)
OR
Diltiazem (Class I, level of evidence C)
OR
Verapamil (Class I, level of evidence C)
OR
Disopyramide (Class IIa, level of evidence C)
OR
Amiodarone (Class IIa, level of evidence C)
OR
Sotalol (Class IIa, level of evidence C)
OR
Flecainide (Class IIa, level of evidence C)
OR
Propafenone (Class IIa, level of evidence C)
Asymptomatic or symptomatic incessent atrial tachycardia Catheter ablation (Class I, level of evidence B)
Asymptomatic and non-sustained atrial tachycardia No therapy (Class I, level of evidence C)
OR

Catheter ablation (Class III, level of evidence C)

Focal and Nonparoxysmal Junctional Tachycardia

Management of focal and nonparoxysmal junctional tachycardia
Focal junctional tachycardia
Beta blockers (Class IIa, level of evidence C)
OR
Amiodarone (Class IIa, level of evidence C)
OR
Sotalol (Class IIa, level of evidence C)
OR
Flecainide (Class IIa, level of evidence C)
OR
Propafenone (Class IIa, level of evidence C)
OR
Catheter ablation (Class IIa, level of evidence C)
Non paroxysmal junctional tachycardia
Reverse digitalis toxicity (Class I, level of evidence C)
AND
Correct hypokalemia (Class I, level of evidence C)
AND
Treat myocardial ischemia (Class I, level of evidence C)
OR
Beta blockers (Class IIa, level of evidence C)
OR
Calcium channel blockers (Class IIa, level of evidence C)

AVNRT

Management of recurrent AVNRT
AVNRT with hemodynamic intolerance
Catheter ablation (Class I, level of evidence B)
OR
Verapamil (Class IIa, level of evidence C)
OR
Diltiazem (Class IIa, level of evidence C)
OR
Beta blockers (Class IIa, level of evidence C)
OR
Amiodarone (Class IIa, level of evidence C)
OR
Sotalol (Class IIa, level of evidence C)
OR
Flecainide (Class IIa, level of evidence C)
OR
Propafenone (Class IIa, level of evidence C)
Recurrent symptomatic AVNRT
Catheter ablation (Class I, level of evidence B)
OR
Verapamil (Class I, level of evidence B)
OR
Diltiazem (Class I, level of evidence C)
OR
Beta blockers (Class IIa, level of evidence C)
OR
Digoxin (Class IIb, level of evidence C)
Recurrent AVNRT unresponsive to beta blockers and calcium channel blockers,
patient not desiring radiofrequency ablation
Flecainide (Class IIa, level of evidence B)
OR
Propafenone (Class IIa, level of evidence B)
OR
Sotalol (Class IIa, level of evidence B)
OR
Amiodarone (Class IIb, level of evidence C)
Single episode of AVNRT or infrequent AVNRT
in patients desiring complete control of arrhythmia
Catheter ablation (Class I, level of evidence B)
Documented PSVT with only dual AV nodal pathways OR
single echo beats documented during electrophysiological study AND
no other cause of arrhythmia identified
Verapamil (Class I, level of evidence C)
OR
Diltiazem (Class I, level of evidence C)
OR
Beta blockers (Class I, level of evidence C)
OR
Flecainide (Class I, level of evidence C)
OR
Propafenone (Class I, level of evidence C)
OR
Catheter ablation (Class I, level of evidence B)
Infrequent, well tolerated AVNRT
No therapy (Class I, level of evidence C)
OR
Vagal maneuvers (Class I, level of evidence B)
OR
Pill in the pocket (Class I, level of evidence B)
OR
Verapamil (Class I, level of evidence B)
OR
Diltiazem (Class I, level of evidence B)
OR
Beta blockers (Class I, level of evidence B)
OR
Catheter ablation (Class I, level of evidence B)

Inappropriate Sinus Tachycardia

Management of inappropriate sinus tachycardia
Beta blockers (Class I, level of evidence C)
OR
Verapamil (Class I, level of evidence C)
OR
Diltiazem (Class I, level of evidence C)
OR
Catheter ablation (Class I, level of evidence B)

Do's

  • Consider the arrhythmia to be paroxysmal if it is recurrent and abruptly begins and terminates.
  • Identify possible triggers and educate the patient to avoid them.
  • Refer patients with narrow complex tachycardia with any of the following to a cardiac arrhythmia specialist:
  • Consider trying different types of anti-arrhythmic agents in case the SVT is refractory; however, closely monitor the blood pressure and heart rate.[3]
  • Consider invasive electrophysiological investigation in the presence of pre-excitation and severe disabling symptoms.
  • Administer higher doses of adenosine in patients taking theophylline.
  • Perform the following tests when indicated:
  • Echocardiography in case of sustained SVT to rule out structural heart disease
  • 24 hour holter monitor in case of frequent but transient tachycardia
  • Loop recorder in patients with less frequent arrhythmia
  • Trans-esophageal atrial recordings if other investigations have failed to document an arrhythmia

Don'ts

  • Do not perform esophageal stimulation if an invasive electrophysiological investigation is planned.
  • Do not initiate treatment with anti-arrhythmic agents in a patient with undocumented arrhythmia.
  • Do not administer adenosine in patients with severe bronchial asthma or heart transplant recipients.[3]

References

  1. 1.0 1.1 "Part 8: Adult Advanced Cardiovascular Life Support". Retrieved 3 April 2014.
  2. 2.0 2.1 2.2 "ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary". Retrieved 15 August 2013.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 Delacrétaz E (2006). "Clinical practice. Supraventricular tachycardia". N Engl J Med. 354 (10): 1039–51. doi:10.1056/NEJMcp051145. PMID 16525141.
  4. Link MS (2012). "Clinical practice. Evaluation and initial treatment of supraventricular tachycardia". N Engl J Med. 367 (15): 1438–48. doi:10.1056/NEJMcp1111259. PMID 23050527.
  5. "Tips From Other Journals - American Family Physician". Retrieved 3 April 2014.


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