Narrow complex tachycardia resident survival guide: Difference between revisions
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{{familytree | {{familytree | | | | | | | | A01 | | A01=<div style="float: left; text-align: left; width: 27em; padding:1em;"> '''Characterize the symptoms:'''<br> | ||
<table> | <table> | ||
<tr class="v-firstrow"><th>❑ Asymptomatic </th><th>❑ [[Palpitations]]</th><th>❑ [[Dyspnea]] </th></tr> | <tr class="v-firstrow"><th>❑ Asymptomatic </th><th>❑ [[Palpitations]]</th><th>❑ [[Dyspnea]] </th></tr> | ||
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❑ Frequency | ❑ Frequency | ||
</div> }} | </div> }} | ||
{{familytree | {{familytree | | | | | | | | |!| | | }} | ||
{{familytree | {{familytree | | | | | | | | B01 | | | B01= <div style="float: left; text-align: left; width: 27em; padding:1em;"> '''Identify possible triggers:'''<br> | ||
<table> | <table> | ||
<tr class="v-firstrow"><th>❑ [[Infection]]</th><th>❑ [[Caffeine]]</th><th>❑ [[Alcohol]]</th></tr> | <tr class="v-firstrow"><th>❑ [[Infection]]</th><th>❑ [[Caffeine]]</th><th>❑ [[Alcohol]]</th></tr> | ||
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<tr><td>❑ [[Pumonary embolism]]</td><td> [[Coronary thrombosis]]</td><td> [[Trauma]] </td></tr></table> | <tr><td>❑ [[Pumonary embolism]]</td><td> [[Coronary thrombosis]]</td><td> [[Trauma]] </td></tr></table> | ||
</div>}} | </div>}} | ||
{{familytree | {{familytree | | | | | | | | |!| | | }} | ||
{{familytree | {{familytree | | | | | | | | C01 | | C01= <div style="float: left; text-align: left; width: 27em; padding:1em;"> ❑ Examine the patient <br> ❑ Order an [[EKG]] </div>}} | ||
{{familytree | {{familytree | | | | | | | | |!| | | }} | ||
{{familytree | {{familytree | | | | | | | | A01 | | | | | A01='''[[Narrow complex tachycardia]]'''<br>[[QRS]] < 120ms}} | ||
{{familytree | | | | | | | | |!| | | | | | | }} | |||
{{familytree | | | | | | | | |!| | | | | | | | |||
{{familytree | | | | | |,|-|-|^|-|-|-|.| | | | | | }} | {{familytree | | | | | |,|-|-|^|-|-|-|.| | | | | | }} | ||
{{familytree | | | | | D01 | | | | | D02 | | | | | |D01='''Undocumented arrhythmia'''|D02='''Documented arrhythmia'''}} | {{familytree | | | | | D01 | | | | | D02 | | | | | |D01='''Undocumented arrhythmia'''|D02='''Documented arrhythmia'''}} | ||
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‡ [[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.<br> | ‡ [[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.<br> | ||
<span style="font-size:85%">'''AF''': Atrial fibrillation; '''AV''': Atrioventricular; '''BBB''': Bundle-branch block; ''' IV''':Intravenous; '''QRS''': Ventricular activation on ECG; '''VT''': Ventricular tachycardia; '''LV''': Left ventricle; SVT: Supraventricular tachycardia</span> <br> | <span style="font-size:85%">'''AF''': Atrial fibrillation; '''AV''': Atrioventricular; '''BBB''': Bundle-branch block; ''' IV''':Intravenous; '''QRS''': Ventricular activation on ECG; '''VT''': Ventricular tachycardia; '''LV''': Left ventricle; SVT: Supraventricular tachycardia</span> <br> | ||
==Additional Management== | |||
{{familytree/start}} | |||
{{familytree | | | | | | | | C01 | | | | | | | |C01=<div style="float: left; text-align: left; height: em; width: 22em; padding:1em;">'''Order tests'''<br> | |||
❑ [[ECG]]<br>❑ [[Echocardiography]] <br> | |||
: ❑ In patients with sustained [[SVT]]†<br> | |||
❑ 24 hour [[holter monitor]]<br> | |||
: ❑ In patients with frequent but transient tachycardia<br> | |||
❑ Loop recorder<br> | |||
: ❑ In patients with less frequent arrhythmias<br> | |||
❑ Trans-esophageal atrial recordings<br> | |||
: ❑ If other investigations have failed to document an arrhythmia</div>}} | |||
{{familytree/end}} | |||
==Do's== | ==Do's== | ||
* Refer narrow complex tachycardic patients with following characteristics to a cardiac arrhythmia specialist: | * Refer narrow complex tachycardic patients with following characteristics to a cardiac arrhythmia specialist: |
Revision as of 16:50, 3 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
Shown below is an algorithm summarizing a stepwise approach to the initial diagnosis of an arrhythmia. Algorithm is according to the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias.[1]
Characterize the symptoms:
Characterize the timing of the symptoms: | |||||||||||||||||||||||||||||||||||||||
Identify possible triggers: | |||||||||||||||||||||||||||||||||||||||
❑ Examine the patient ❑ Order an EKG | |||||||||||||||||||||||||||||||||||||||
Narrow complex tachycardia QRS < 120ms | |||||||||||||||||||||||||||||||||||||||
Undocumented arrhythmia | Documented arrhythmia | ||||||||||||||||||||||||||||||||||||||
❑ 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. | |||||||||||||||||||||||||||||||||||||
† In patients with sustained SVT, echocardiography is performed to rule out structural heart disease.
SVT: Supra ventricular tachycardia; ECG: Electrocardiograph
Management
Differential Diagnosis for Narrow QRS Tachycardia
Shown below is an algorithm summarizing the approach to differentiate various types of narrow complex tachycardia. Algorithm is according to the 2003 guidelines issued by ACC/AHA/ESC for the management of patients with supraventricular arrhythmias.[1]
Narrow QRS tachycardia (QRS duration less than 120 ms) | |||||||||||||||||||||||||||||||||||||||||||
Regular rhythm | Irregular rhythm | ||||||||||||||||||||||||||||||||||||||||||
❑ Analyze presence of P waves | Consider following causes ❑ Atrial fibrillation | ||||||||||||||||||||||||||||||||||||||||||
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: Atrioventricular; AVNRT: Atrioventricular nodal reciprocating tachycardia; MAT: Multifocal atrial tachycardia; ms: miliseconds; PJRT: Permanent form of junctional reciprocating tachycardia; QRS: Ventricular activation on ECG
Differential Diagnosis of Narrow Complex Tachycardias According to Adenosine Response
Shown below is an algorithm summarizing the approach to differential diagnosis of narrow complex tachycardia according to the adenosine response. Algorithm is according to the 2003 guidelines issued by ACC/AHA/ESC for the management of patients with supraventricular arrhythmias.[1]
Regular narrow QRS complex tachycardia | |||||||||||||||||||||||||||||||||||||||||||||||
❑ Administer IV adenosine | |||||||||||||||||||||||||||||||||||||||||||||||
❑ Analyze changes on ECG | |||||||||||||||||||||||||||||||||||||||||||||||
No change in rate | Gradual slowing then re-acceleration of rate | Abrupt termination | Persisting atrial tachycardia with transient high-grade AV block | ||||||||||||||||||||||||||||||||||||||||||||
❑ Consider inadequate dose/delivery ❑ Consider VT (fascicular or high septal origin) | ❑ Consider following
| ||||||||||||||||||||||||||||||||||||||||||||||
AV: Atrioventricular; AVNRT: Atrioventricular nodal reciprocating tachycardia; AVRT: Atrioventricular reciprocating tachycardia; IV:Intravenous; QRS: Ventricular activation on ECG; VT: Ventricular tachycardia
Acute management of Hemodynamically Stable Narrow QRS Regular Tachycadia
Show below is an algorithm summarizing the approach to management of narrow complex tachycardia. Algorithm is according to the 2003 guidelines issued by ACC/AHA/ESC for the management of patients with supraventricular arrhythmias.[1]
Hemodynamically stable regular tachycardia | |||||||||||||||||||||||||||||||||||||||||||
❑ Confirm diagnosis of narrow QRS complex tachycardia | |||||||||||||||||||||||||||||||||||||||||||
❑ Perform vagal maneuvers
❑ Administer IV adenosine†
❑ Administer IV verapamil/diltiazem
| |||||||||||||||||||||||||||||||||||||||||||
Arrhythmia terminated | Persistent tachycardia with AV block | ||||||||||||||||||||||||||||||||||||||||||
❑ Administer 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: Atrial fibrillation; AV: Atrioventricular; BBB: Bundle-branch block; IV:Intravenous; QRS: Ventricular activation on ECG; VT: Ventricular tachycardia; LV: Left ventricle; SVT: Supraventricular tachycardia
Additional Management
Order tests
❑ 24 hour holter monitor
❑ Loop recorder
❑ Trans-esophageal atrial recordings
| |||||||||||||||||||||||||||||||||
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.
- Consider invasive electrophysiological investigation in presence of pre-excitation and severe disabling symptoms.
- Order a 12 lead ECG during use of adenosine or carotid massage.
- Consider esophageal pill electrodes in cases of invisible P waves.
- Administer higher doses of adenosine in patients taking theophylline.
- Administer IV adenosine or DC cardioversion in patients with PSVT requiring a rapid therapeutic effect.
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.
References
- ↑ 1.0 1.1 1.2 1.3 "ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary". Retrieved 15 August 2013.
- ↑ 2.0 2.1 2.2 2.3 Ray IB (2004). "Narrow complex tachycardia: recognition and management in the emergency room". J Assoc Physicians India. 52: 816–24. PMID 15909859.