Narrow complex tachycardia resident survival guide

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.

• Wolff-Parkinson-White syndrome (orthodromic AVRT)
• Idiopathic fascicular ventricular tachycardia

Common Causes

• Atrial fibrillation
• Atrial flutter
• Atrial tachycardia
• AVNRT
• AVRT

Classification

• Atrial fibrillation
  
• Atrial flutter
  
• Atrial tachycardia
  
• Atrioventricular reentrant tachycardia (AVRT)
  
• AV nodal reentrant tachycardia (AVNRT)
  
• Inappropriate sinus tachycardia
  
• Intraatrial reentrant tachycardia (IART)
  
• Junctional tachycardia
  
• Multifocal atrial tachycardia
  
• Sinus node re-entry tachycardia
  
• Sinus tachycardia
  

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.

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

Continue with the diagnostic approach

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.
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

Identify possible triggers: ❑ Infection ❑ Caffeine ❑ Alcohol ❑ Nicotine ❑ Recreational drugs ❑ Hypovolemia ❑ Hyperthyroidism ❑ Hypoxia ❑ Acidosis ❑ Hypokalemia ❑ Hyperkalemia ❑ Hypoglycemia ❑ Hypothermia ❑ Toxins ❑ Pulmonary embolism ❑ Coronary thrombosis ❑ Trauma

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.
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.
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.
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.
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

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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. ❑ 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) ❑ 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 ❑ 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 ❑ 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 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:

• Drug resistance
• Intolerance to drugs
• Refusal of drug therapy
• Severe symptoms such as syncope and dyspnea
• Wolff-Parkinson-White syndrome

• Consider trying different types of anti-arrhythmic agents in case the SVT is refractory; however, closely monitor the blood pressure and heart rate.

• Consider invasive electrophysiological investigation in the presence of pre-excitation and severe disabling symptoms.

• Monitor the 12 lead ECG during the administration ofadenosine or carotid massage.

• Make sure the equipment for resuscitation is available during the administration of adenosine in case of the occurrence of any complication, such as ventricular fibrillation or bronchospasm.

• 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.

References

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