Narrow complex tachycardia resident survival guide: Difference between revisions
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{{familytree | | | | | D02 | | | | | D01 | | | | | |D01='''Undocumented arrhythmia'''|D02='''Documented arrhythmia'''}} | {{familytree | | | | | D02 | | | | | D01 | | | | | |D01=<div style="float: left; text-align: left; height: em; width: em; padding:1em;"> '''Undocumented arrhythmia'''<br> ([[EKG]]is normal or does not suggest mechanism of arrhythmia)</div>|D02=<div style="float: left; text-align: left; height: em; width: em; padding:1em;">'''Documented arrhythmia''' (Arrhythmia mechanism is documented on [[EKG]])</div>}} | ||
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{{familytree | | | E04 | | E03 | | E01 | | E02 | |E01=<div style="float: left; text-align: left; height: 5em; width: 12em; padding:1em;"> ❑ History suggests extra premature beats | {{familytree | | | E04 | | E03 | | E01 | | E02 | |E01=<div style="float: left; text-align: left; height: 5em; width: 12em; padding:1em;"> ❑ History suggests extra premature beats.</div> |E02=<div style="float: left; text-align: left; height: em; width: 12em; padding:1em;"> ❑ History suggests paroxysmal 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>}} | ||
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{{familytree | | | F04 | | F03 | | F01 | | F02 | |F01=<div style="float: left; text-align: left; height: em; width: 12em; padding:1em;"> Rule out following:<br> | {{familytree | | | F04 | | F03 | | F01 | | F02 | |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>|F03=<div style="float: left; text-align: left; height: em; width: 12em; padding:1em;">❑ Confirm diagnosis of narrow QRS complex tachycardia.</div>|F04=<div style="float: left; text-align: left; height: em; width: 12em; padding:1em;" | ❑ [[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;">❑ Confirm diagnosis of narrow QRS complex tachycardia.</div>|F04=<div style="float: left; text-align: left; height: em; width: 12em; padding:1em;">❑ Immediate direct current [[cardioversion]].</div>}} | ||
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{{familytree | | | | | | | D01 | | | | | | D01=<div style="float: left; text-align: left; height: em; width: 25em; padding:1em;"> | {{familytree | | | | | | | D01 | | | | | | D01=<div style="float: left; text-align: left; height: em; width: 25em; padding:1em;"> |
Revision as of 23:05, 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
Management
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 | |||||||||||||||||||||||||||||||||||||||||
❑ Analyze EKG | |||||||||||||||||||||||||||||||||||||||||
Documented arrhythmia (Arrhythmia mechanism is documented on EKG) | Undocumented arrhythmia (EKGis normal or does not suggest mechanism of arrhythmia) | ||||||||||||||||||||||||||||||||||||||||
Unstable patient | Stable patient | ❑ History suggests extra premature beats. | ❑ History suggests paroxysmal arrhythmia. | ||||||||||||||||||||||||||||||||||||||
❑ Immediate direct current cardioversion. | ❑ Confirm diagnosis of narrow QRS complex tachycardia. | ❑ Refer for an invasive electrophysiological study AND/OR ❑ Catheter ablation ❑ Teach vagal maneuvers to patients. ❑ Consider beta blocking agent. | |||||||||||||||||||||||||||||||||||||||
❑ Perform vagal maneuvers
❑ Administer IV adenosine†
❑ Administer IV verapamil/diltiazem
| |||||||||||||||||||||||||||||||||||||||||
❑ Perform EKG simultaneously with adenosine administration | |||||||||||||||||||||||||||||||||||||||||
❑ 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
| ||||||||||||||||||||||||||||||||||||||||
Arrhythmia terminated | Persistent tachycardia with AV block | ||||||||||||||||||||||||||||||||||||||||
❑ Administer IV ibutilide‡ PLUS ❑ AV-nodal-blocking agent ❑ Overdrive pacing/DC cardioversion, and/or ❑ Rate control | |||||||||||||||||||||||||||||||||||||||||
† In patients with sustained SVT, echocardiography is performed to rule out structural heart disease.
† 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; SVT: Supra ventricular tachycardia; ECG: Electrocardiograph; AVNRT: Atrioventricular nodal reciprocating tachycardia; AVRT: Atrioventricular reciprocating tachycardia
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) | |||||||||||||||||||||||||||||||||||||||||||
❑ Determine the regularity of rhythm | |||||||||||||||||||||||||||||||||||||||||||
Regular rhythm | Irregular rhythm | ||||||||||||||||||||||||||||||||||||||||||
Consider following causes: ❑ Atrial fibrillation | |||||||||||||||||||||||||||||||||||||||||||
❑ Determine if P waves are visible. | |||||||||||||||||||||||||||||||||||||||||||
P waves are not visible | P waves are visible | ||||||||||||||||||||||||||||||||||||||||||
❑ Consider AVNRT | ❑ Determine if atrial rate is greater than ventricular rate. | ||||||||||||||||||||||||||||||||||||||||||
Atrial rate > Ventricular rate | Atrial rate ≤ Ventricular rate | ||||||||||||||||||||||||||||||||||||||||||
❑ Consider Atrial flutter or atrial tachycardia | ❑ Determine if RP interval > PR interval | ||||||||||||||||||||||||||||||||||||||||||
No (RP < PR) | Yes (RP > PR) | ||||||||||||||||||||||||||||||||||||||||||
❑ Determine the duration of RP interval. | |||||||||||||||||||||||||||||||||||||||||||
< 70 ms | > 70 ms | ||||||||||||||||||||||||||||||||||||||||||
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
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 "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.