Narrow complex tachycardia resident survival guide: Difference between revisions

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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.<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> <br>
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.<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> <br>
<span style="font-size:85%">'''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 </span>
<span style="font-size:85%">'''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 </span>
{{familytree/start}}
{{familytree/start}}
{{familytree | | | D01 | | D01=<div style="float: left; text-align: left; width: 35em; padding:1em;">'''Acute management:'''<br>
{{familytree | | | A01 | | A01= Assess the hemodynamic status of the patient <br> Signs of hemodynamic instability include: <br>
❑ Hypotension <br>
❑ Acute altered mental status <br>
❑ Signs of shock <br>
❑ Acute heart failure<br>
❑ Chest discomfort suggestive of ischemia<br>}}
{{familytree | |,|-|^|-|.| | }}
{{familytree | B01 | | B02 | B01= Stable | B02= Unstable }}
{{familytree | |!| | | |!| | | | | }}
{{familytree | C01 | | C02 | | | | C01= Synchronized cardioversion| C02= Does the patient have any of the following? <br> [[Atrial fibrillation]] <br> [[Atrial flutter]] <br> [[Wolff Parkinson Wolff syndrome]] (orthodromic AVRT)}}
{{familytree | | | |,|-|^|-|.| | | }}
{{familytree | | | C03 | | C04 | | | C03= No | C04= Yes }}
{{familytree | | | |!| | | |!| | }}
{{familytree | | | D01 | | D02=<div style="float: left; text-align: left; width: 35em; padding:1em;">'''Acute management:'''<br>
❑ Perform vagal maneuvers ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])<br>
❑ Perform vagal maneuvers ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])<br>
: ❑ [[Valsalva maneuver]]<br>
: ❑ [[Valsalva maneuver]]<br>
: ❑ [[Carotid sinus massage]]<br>
: ❑ [[Carotid sinus massage]]<br>
❑ Monitor [[ECG]] continuously</div>}}
❑ Monitor [[ECG]] continuously</div>| D02=}}
{{familytree | | | |!| | | | |}}
{{familytree | | | |!| | | | |}}
{{familytree | | | D02 | | |D02=<div style="float: left; text-align: left; width: 35em; padding:1em;">'''If vagal maneuvers fail:'''<br>
{{familytree | | | D02 | | | | D02=<div style="float: left; text-align: left; width: 35em; padding:1em;">'''If vagal maneuvers fail:'''<br>
❑ Administer IV [[adenosine]]† ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]])<br>
❑ Administer IV [[adenosine]]† ([[ACC AHA guidelines classification scheme|Class I, level of evidence A]])<br>
:❑ First dose: 6 mg rapid IV push, followed by 20 mL of [[normal saline]] bolus
:❑ First dose: 6 mg rapid IV push, followed by 20 mL of [[normal saline]] bolus

Revision as of 16:32, 3 April 2014

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]

Synonyms and keywords: Supraventricular tachycardia, SVT

Narrow Complex Tachycardia Resident Survival Guide Microchapters
Overview
Causes
Classification
Diagnosis
FIRE
Complete
Treatment
Initial
Short term
Specific arrhythmia
Do's
Don'ts

Overview

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

Classification

Diagnosis

First Initial Rapid Evaluation of Suspected Narrow Complex Tachycardia

Shown below is an algorithm for the First Initial Rapid Evaluation (FIRE) of suspected narrow complex tachycardia.[1][2]

Boxes in red signify that an urgent management is needed.

 
 
 
 
 
 
Identify cardinal signs and symptoms that increase the pretest probability of NCT

Palpitations (Most common presentation)
Tachycardia
❑ ECG findings

❑ Heart rate > 100 beats/min
❑ QRS duration < 120 ms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Identify alarming signs and symptoms of hemodynamic instability
Hypotension
Acute altered mental status
❑ Signs of shock
Acute heart failure
Chest discomfort suggestive of ischemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unstable patient
 
 
 
 
 
Stable patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Urgent synchronized cardioversion
❑ Narrow regular rhythm: 50-100 J
❑ Narrow irregular rhythm: 120-200 J biphasic or 200 J monophasic
 
 
 
 
 
 
 
 


Complete Diagnostic Approach to Narrow Complex Tachycardia

Shown below is an algorithm summarizing the diagnostic approach to narrow complex tachycardia according to the 2003 ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias.[1]
Abbreviations: ECG: electrocardiogram; SVT: Supraventricular tachycardia; ms: milliseconds; bpm: beats per minute; NCT: Narrow complex tachycardia; 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
❑ Regularly irregular
❑ Irregularly irregular
❑ 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 in which the rhythm is not sinus tachycardia

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Narrow QRS tachycardia
❑ Heart rate > 100 beats/min
❑ QRS duration < 120 ms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Determine 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

Type of Arrhythmia EKG (lead II)† Clues
Supraventricular tachycardia Any tachyarrhythmia that is initiated and maintained in atrial tissue or atrioventricular junctional tissue.[1]
Sinus tachycardia Rhythm with heart rate > 100 bpm, originating in SA node due to its increased automaticity. It is regular, non paroxysmal and has a gradual onset and termination.
Sinus node re-entry tachycardia Rare paroxysmal tachycardia arising due to re-entry circuits with in SA node.[3]
Atrial fibrillation Supraventricular tachycardia with irregularly irregular rhythm and absent P waves on EKG.
Atrial flutter Cardiac rhythm characterized by an atrial rate ranging from 240 to 400 beats per minute and regular continuous wave-form.[4]
AVNRT Most common form of PSVT with a heart rate of 140-250 bpm, re-entrant circuit involves two separate anatomical pathways (slow and fast) located in perinodal tissue. It is regular and paroxysmal.
AVRT Re-entrant tachycardia occurring due to an accessory pathway in addition to AV node, accessory pathway is essential for the initiation and the maintenance of tachycardia. It is regular and paroxysmal.
Focal atrial tachycardia Focal atria tachycardia refers to a rhythm originating from a single site either in the left or right atrium with an atrial rate of 100-250 bpm.
Nonparoxysmal junctional tachycardia Benign tachycardia occurring due to increased automaticity arising from a high junctional focus.
Multifocal atrial tachycardia Irregular tachycardia characterized by 3 different P wave morphologies on EKG.

EKG strips are courtesy of ECGpedia.

Treatment

Treatment of SVT in a Hemodynamically Stable Patient

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.[1]
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

 
 
Assess the hemodynamic status of the patient
Signs of hemodynamic instability include:

❑ Hypotension
❑ Acute altered mental status
❑ Signs of shock
❑ Acute heart failure

❑ Chest discomfort suggestive of ischemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stable
 
Unstable
 
 
 
 
 
 
 
 
 
 
 
 
 
Synchronized cardioversion
 
Does the patient have any of the following?
Atrial fibrillation
Atrial flutter
Wolff Parkinson Wolff syndrome (orthodromic AVRT)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
{{{ D01 }}}
 
 
 
 
 
 
 
 
 
 
 
 
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.[5]

❑ 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)[5]
❑ 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[5]

❑ 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[5]

❑ Monitor ECG continuously
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Terminated arrhythmia
 
Persistent arrhythmia
 
 
 
 
 
 
 
 
 
 
 
 
 
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
❑ 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[5]

OR

❑ DC cardioversion
 

Adenosine should be used cautiously in patients with severe coronary artery disease and may produce AF.
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.

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.
  • 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.[5]
  • Consider invasive electrophysiological investigation in the presence of pre-excitation and severe disabling symptoms.
  • Consider esophageal pill electrodes in cases of invisible P waves.
  • 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.[5]

References

  1. 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. "Part 8: Adult Advanced Cardiovascular Life Support". Retrieved 3 April 2014.
  3. Cossú, SF.; Steinberg, JS. "Supraventricular tachyarrhythmias involving the sinus node: clinical and electrophysiologic characteristics". Prog Cardiovasc Dis. 41 (1): 51–63. PMID 9717859.
  4. Dhar S, Lidhoo P, Koul D, Dhar S, Bakhshi M, Deger FT (2009). "Current concepts and management strategies in atrial flutter". South. Med. J. 102 (9): 917–22. doi:10.1097/SMJ.0b013e3181b0f4b8. PMID 19668035. Unknown parameter |month= ignored (help)
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 Delacrétaz E (2006). "Clinical practice. Supraventricular tachycardia". N Engl J Med. 354 (10): 1039–51. doi:10.1056/NEJMcp051145. PMID 16525141.


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