Multifocal atrial tachycardia: Difference between revisions

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{{Infobox_Disease |
{{Multifocal atrial tachycardia}}
  Name          = {{PAGENAME}} |
{{CMG}} '''Associate Editor-In-Chief:''' {{S.M.}}, {{CZ}}, {{HK}}
  Image          = MAT 1.jpeg|
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  OMIM          = |
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{{SI}}
 
{{CMG}}; '''Associate Editor-In-Chief:''' {{S.M.}} {{CZ}} {{HK}}


{{SK}} MAT, Chaotic atrial tachycardia, Supraventricular tachycardia
{{SK}} MAT, Chaotic atrial tachycardia, Supraventricular tachycardia
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|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Theory (science)|Theory]] of re-entry
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Theory (science)|Theory]] of re-entry
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* This [[Theory (science)|theory]] centers upon the [[Idealization|idea]] that [[automaticity]] [[Focus (optics)|foci]] having [[Differential geometry|different]] [[Exit counseling|exit]] [[Path analysis (statistics)|pathways]] or [[Electrical circuit|electrical circuits]] with [[abnormal]] [[Intra-atrial conduction delay|intra-atrial conduction]] can [[Product (biology)|produce]] tachycardia with several discrete P wave morphologies. However, the role of re-entrant pathways is still not clear and needs to be explained in detail.
* This [[Theory (science)|theory]] centers upon the [[Idealization|idea]] that [[automaticity]] [[Focus (optics)|foci]] having [[Differential geometry|different]] [[Exit counseling|exit]] [[Path analysis (statistics)|pathways]] or [[Electrical circuit|electrical circuits]] with [[abnormal]] [[Intra-atrial conduction delay|intra-atrial conduction]] can [[Product (biology)|produce]] [[tachycardia]] with several [[Discrete distribution|discrete]] [[P wave]] [[Morphology|morphologies]]. However, the [[Role reversal|role]] of [[Re-entrant arrhythmia|re-entrant pathways]] is still not clear and needs to be [[Explained variance|explained]] in [[Detailed balance|detail]].
* According to different studies, programmed electrical stimulation which both triggers and terminates reentrant rhythms has not been found to have any affect on multifocal atrial tachycardia or to reproduce it.
* According to [[Differential geometry|different]] [[Study design|studies]], [[Programmed instruction|programmed]] [[electrical stimulation]] which both [[Trigger|triggers]] and [[Termination signal|terminates]] [[Re-entrant arrhythmia|reentrant rhythms]] has not been found to have any [[Effect size|effect]] on [[Multifocal atrial tachycardia (MAT)|multifocal atrial tachycardia]] or to [[Reproducibility|reproduce]] it.
* According to one of the [[electrophysiological]] [[Study design|studies]] including [[patients]] of multifocal atrial tachycardia, following three abnormal conduction pathways were found out:
* According to one of the [[electrophysiological]] [[Study design|studies]] including [[patients]] of [[Multifocal atrial tachycardia (MAT)|multifocal atrial tachycardia]], following three [[abnormal]] [[Conduction System|conduction pathways]] were found out:
**Intra-[[atrial]]
**Intra-[[atrial]]
**Atrionodal
**Atrionodal
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|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Theory (science)|Theory]] of [[abnormal]] [[automaticity]]
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Theory (science)|Theory]] of [[abnormal]] [[automaticity]]
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* The theory of abnormal automaticity focuses on an increase in the ability of atrial myocytes to spontaneously depolarize and trigger an action potential.
* The [[Main effect|main]] [[Focus (optics)|focus]] of the [[theory]] of [[Abnormality (behavior)|abnormal]] [[automaticity]] is on an increase in the [[Ability grouping|ability]] of [[atrial myocytes]] to spontaneously [[Depolarization|depolarize]] and thus [[Trigger|triggering]] an [[action potential]].
* This theory is supported by many of the underlying conditions associated with this arrhythmia.
* Many of the [[Underlying representation|underlying]] [[conditions]] [[Association (statistics)|associated]] with [[Multifocal atrial tachycardia (MAT)|MAT]] [[support]] this [[theory]].
* Pulmonary diseases, like COPD, can result in hypoxia, hypercapnia, acidosis, and increased adrenergic stimulation, all of which are known to increase automaticity.
*[[Pulmonary disease|Pulmonary diseases]] such as [[Chronic obstructive pulmonary disease|COPD]] can [[Causes|cause]] any of the following [[pathological]] [[conditions]] known to be [[Association (statistics)|associated]] with an increase in [[automaticity]]:
* Furthermore, pulmonary hypertension associated with pulmonary diseases can result in right atrial enlargement and right atrial hypertension, which can also increase automaticity.
**[[Hypoxia]]
* Similarly, the ventricular dysfunction seen in coronary artery disease and congestive heart failure can result in atrial enlargement and atrial hypertension that can also increase automaticity.
**[[Hypercapnia]]
* The electrolyte abnormalities and medications associated with this arrhythmia, are also known to increase automaticity.
**[[Acidosis]]
* However, given all the above information the role of abnormal automaticity in multifocal atrial tachycardia has not yet been fully understood.
**Increased [[adrenergic]] [[Stimulated emission|stimulation]]
*[[Pulmonary hypertension]] [[Association (statistics)|associated]] with [[Pulmonary disease|pulmonary diseases]] can also [[result]] in [[right atrial enlargement]], in turn, [[Causes|causing]] [[right atrial]] [[hypertension]] [[Lead|leading]] to an increase in [[automaticity]].
*[[Ventricular dysfunction]] [[Association (statistics)|associated]] with [[coronary artery disease]] and [[congestive heart failure]] can [[lead]] to [[atrial]] enlargement and [[atrial]] [[hypertension]] which can also increase the [[automaticity]].
*[[Medications]] and [[electrolyte abnormalities]] [[Association (statistics)|associated]] with [[Multifocal atrial tachycardia (MAT)|MAT]] are also known to increase the [[automaticity]].
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|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Theory (science)|Theory]] of [[Trigger|triggered]] [[Activity (chemistry)|activity]]
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Theory (science)|Theory]] of [[Trigger|triggered]] [[Activity (chemistry)|activity]]
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* The theory of triggered activity involves spontaneous action potentials generated from afterdepolarizations due to myocardial cell membrane instability.
* This [[theory]] involves the spontaneous [[action potentials]] which are generated from after[[Depolarization|depolarizations]] due to the [[instability]] of the [[myocardial]] [[cell membrane]].
* According to this theory, a normal stimulus, such as an action potential generated by the sinoatrial node, gives rise to afterdepolarizations due to changes in membrane potential that can achieve threshold and “trigger” spontaneous action potentials.
* It [[States of matter|states]] that a [[normal]] [[stimulus]] such as an [[action potential]] generated by a [[sinoatrial node]] [[Lead|leads]] to after[[Depolarization|depolarizations]] due to the [[membrane potential]] [[Change detection|changes]] which can [[Achievement test|achieve]] [[Threshold Limit Value|threshold]] and “[[trigger]]” the spontaneous [[action potentials]].
* It is proposed that intracellular calcium overload may lead to afterdepolarization which can result in triggered activity.
*[[Intracellular]] [[calcium]] overload can also [[lead]] to after[[depolarization]] which can [[result]] in the [[Trigger|triggered]] [[Activity (chemistry)|activity]].
* This theory also has yet to be elucidated, however, the effectiveness of calcium channel blockers, such as verapamil, which may act to reduce the intracellular calcium overload, supports this theory.
* This [[theory]] of [[Trigger|triggered]] [[Activity (chemistry)|activity]] still needs to be [[Explained variance|explained]] clearly, however, the [[Effective method|effectiveness]] of [[calcium channel blockers]], such as [[verapamil]] [[Acting out|acting]] to [[Reduced|reduce]] the [[intracellular]] [[calcium]] overload, [[Support|supports]] this [[theory]].
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[[image:MAT.jpg|thumb|700px|none|Multifocal Atrial Tachycardia.]]
[[image:MAT.jpg|thumb|500px|none|Multifocal Atrial Tachycardia.]]
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[[File:Multifocal atrial tachycardia - MAT.png|thumb|450px|none|Multifocal atrial tachycardia (MAT) [https://en.wikipedia.org/wiki/Multifocal_atrial_tachycardia#/media/File:Multifocal_atrial_tachycardia_-_MAT.png]]
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==Epidemiology and Demographics==
==Epidemiology and Demographics==
*[[Multifocal atrial tachycardia (MAT)|MAT]] has been [[Reporting results|reported]] in >20% of the [[pediatric]] [[patients]] and up to 60% of the [[adult]] [[patients]] with coexisting [[pulmonary disease]].
*Although the prevalence of pulmonary disease in MAT has been well established in adult MAT patients, particularly those with pulmonary diseases including chronic obstructive pulmonary disease, it is relatively rare in the pediatric ages. Therefore, the clinical feature of MAT in children is not well known with several studies of small cases.<ref name="pmid24750225">{{cite journal| author=Lazaros G, Chrysohoou C, Oikonomou E, Tsiachris D, Mazaris S, Venieri E | display-authors=etal| title=The natural history of multifocal atrial rhythms in elderly outpatients: insights from the "Ikaria study". | journal=Ann Noninvasive Electrocardiol | year= 2014 | volume= 19 | issue= 5 | pages= 483-9 | pmid=24750225 | doi=10.1111/anec.12165 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24750225  }} </ref>
* rare multifocal atrial tachycardia in the neonate, initiated by a recent case in our clinic. The difficulties in prenatally diagnosing the disease by cardiotocography are as well discussed as the obstetric management.<ref name="pmid4072318">{{cite journal| author=Haenel AF, Olafsson A| title=[Multifocal atrial tachycardia in the newborn infant--obstetrical implications]. | journal=Z Geburtshilfe Perinatol | year= 1985 | volume= 189 | issue= 5 | pages= 228-31 | pmid=4072318 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4072318  }} </ref><ref name="pmid3660970">{{cite journal| author=Esterl D, Rösel HD| title=[Multifocal (chaotic) atrial tachycardia in a newborn infant]. | journal=Zentralbl Gynakol | year= 1987 | volume= 109 | issue= 14 | pages= 919-22 | pmid=3660970 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3660970  }} </ref><ref name="pmid21267831">{{cite journal| author=Bouziri A, Khaldi A, Hamdi A, Ben Massoud I, Borgi A, Menif K | display-authors=etal| title=Multifocal atrial tachycardia: an unusual cause of cardiogenic shock in a newborn. | journal=Tunis Med | year= 2011 | volume= 89 | issue= 1 | pages= 59-61 | pmid=21267831 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21267831  }} </ref>
*Multifocal atrial tachycardia is a relatively uncommon arrhythmia seen in 0.05% to 0.32% of electrocardiograms in general hospital admissions. The average age of patients is approximately 70 years.<ref name="pmid29083603">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=29083603 | doi= | pmc= | url= }} </ref>
*The incidence of multifocal atrial tachycardia (MAT) is very low and accounts for less than 1% of supraventricular tachycardia in infants and children.<ref name="pmid17051756">{{cite journal| author=Hsieh MY, Lee PC, Hwang B, Meng CC| title=Multifocal atrial tachycardia in 2 children. | journal=J Chin Med Assoc | year= 2006 | volume= 69 | issue= 9 | pages= 439-43 | pmid=17051756 | doi=10.1016/S1726-4901(09)70288-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17051756  }} </ref>
*Multifocal atrial tachycardia is a rare form of rhythm disturbance in infancy; it is difficult to treat but frequently resolves spontaneously within the first year of life.<ref name="pmid6737948">{{cite journal| author=Toussaint R, Hofstetter R, von Bernuth G| title=[Multifocal atrial tachycardia in infancy]. | journal=Klin Padiatr | year= 1984 | volume= 196 | issue= 2 | pages= 118-20 | pmid=6737948 | doi=10.1055/s-2007-1025591 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6737948  }} </ref>


==Natural history, Complications, and Prognosis==
*[[Multifocal atrial tachycardia (MAT)|Multifocal atrial tachycardia]] is a [[Relatively compact|relatively]] uncommon [[Cardiac arrhythmia|arrhythmia]] with low [[Incidence (epidemiology)|incidence]].
*MAT is considered to be a relatively benign arrhythmia with likely good outcome if there is no severe underlying illness. It can be well controlled under appropriate drugs, and a long period of follow-up is suggested. If pharmacologic intervention is required, we suggest that amiodarone may be an excellent choice.<ref name="pmid17051756">{{cite journal| author=Hsieh MY, Lee PC, Hwang B, Meng CC| title=Multifocal atrial tachycardia in 2 children. | journal=J Chin Med Assoc | year= 2006 | volume= 69 | issue= 9 | pages= 439-43 | pmid=17051756 | doi=10.1016/S1726-4901(09)70288-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17051756  }} </ref>
*It is seen only in 0.05% to 0.32% of [[electrocardiograms]] in general [[hospital]] [[Admission note|admissions]].
*Baek et al reported the clinical outcome of MAT and potential prognostic factors. Compared to the previous reports, this study has relatively large number of patients and composed of various etiologies despite of limitation of retrospective study from single tertiary center. Among 33 patients with identified MAT, 27 (82%) were infantile onset and 10 patients (30%) had fetal diagnosis. Incidental detection without significant clinical manifestation is rather high (27%). Comorbidities had a variety of SHD (42%) and lung disease (24%). Interestingly, syndromic diagnosis, including 3 with Costello syndrome and 2 with Noonan syndrome, and one suggestive of RASopathy were noted in infantile onset group. Among 27 patients with infant onset of MAT, 11 patients (41%) were included in the idiopathic group. Accompanying arrhythmias was revealed in 4 patients (2 atrioventricular reentrant tachycardia prior to MAT diagnosis; 2 catecholaminergic polymorphic ventricular tachycardia [CPVT] after MAT diagnosis). The arrhythmia control rate was higher in the infant group (85%) than in the non-infant group (67%), although this trend was not statistically significant. There was a significantly lower rate of unfavorable outcomes in the idiopathic infant group (n=11) than in the other groups (p=0.008). Considering the findings of previous studies, the mortality rate was significantly higher in patients with SHD than in patients without (21% vs. 5%, p=0.01). The idiopathic infant group had a significantly lower rate of unfavorable outcomes than did the others (0% vs. 47%, p=0.008).<ref name="pmid29441747">{{cite journal| author=Baek SM, Chung H, Song MK, Bae EJ, Kim GB, Noh CI| title=The Complexity of Pediatric Multifocal Atrial Tachycardia and Its Prognostic Factors. | journal=Korean Circ J | year= 2018 | volume= 48 | issue= 2 | pages= 148-158 | pmid=29441747 | doi=10.4070/kcj.2017.0179 | pmc=5861005 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29441747  }} </ref>
*The [[average]] [[age]] of [[patients]] [[Affect|affected]] by [[Multifocal atrial tachycardia (MAT)|MAT]] is approximately 70 [[Year|years]].<ref name="pmid29083603">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=29083603 | doi= | pmc= | url= }} </ref>
*While most patients with multifocal atrial tachycardia are hemodynamically stable, it is a poor prognostic sign in the setting of an acute illness. Studies have shown a 60% in-hospital mortality and mean survival of just over one year.<ref name="pmid30571060">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30571060 | doi= | pmc= | url= }} </ref><ref name="pmid30055033">{{cite journal| author=Levin MD, Saitta SC, Gripp KW, Wenger TL, Ganesh J, Kalish JM | display-authors=etal| title=Nonreentrant atrial tachycardia occurs independently of hypertrophic cardiomyopathy in RASopathy patients. | journal=Am J Med Genet A | year= 2018 | volume= 176 | issue= 8 | pages= 1711-1722 | pmid=30055033 | doi=10.1002/ajmg.a.38854 | pmc=6107379 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30055033  }} </ref>
*[[Prevalence]] of [[pulmonary disease]] in [[Multifocal atrial tachycardia (MAT)|MAT]] has been [[WellPoint|well]] established in [[adult]] [[Multifocal atrial tachycardia (MAT)|MAT]] [[patients]] with up to 60% of the [[adult]] [[patients]] having a coexisting [[pulmonary disease]], particularly those with [[chronic obstructive pulmonary disease]].
*[[Multifocal atrial tachycardia (MAT)|MAT]] is a [[Relatively compact|relatively]] [[rare]] [[condition]] with [[clinical]] [[Features (pattern recognition)|features]] not [[WellPoint|well]] established in [[pediatric]] [[Age|ages]].
*It accounts for less than 1% of [[supraventricular tachycardia]] in [[infants]] and [[children]] and is [[Reporting results|reported]] to [[affect]] >20% of the [[pediatric]] [[patients]].<ref name="pmid24750225">{{cite journal| author=Lazaros G, Chrysohoou C, Oikonomou E, Tsiachris D, Mazaris S, Venieri E | display-authors=etal| title=The natural history of multifocal atrial rhythms in elderly outpatients: insights from the "Ikaria study". | journal=Ann Noninvasive Electrocardiol | year= 2014 | volume= 19 | issue= 5 | pages= 483-9 | pmid=24750225 | doi=10.1111/anec.12165 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24750225  }} </ref><ref name="pmid17051756">{{cite journal| author=Hsieh MY, Lee PC, Hwang B, Meng CC| title=Multifocal atrial tachycardia in 2 children. | journal=J Chin Med Assoc | year= 2006 | volume= 69 | issue= 9 | pages= 439-43 | pmid=17051756 | doi=10.1016/S1726-4901(09)70288-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17051756  }} </ref>
*[[Multifocal atrial tachycardia (MAT)|Multifocal atrial tachycardia]] though [[rare]] in [[neonates]], can be [[Diagnose|diagnosed]] [[Prenatal|prenatally]] by [[cardiotocography]].<ref name="pmid4072318">{{cite journal| author=Haenel AF, Olafsson A| title=[Multifocal atrial tachycardia in the newborn infant--obstetrical implications]. | journal=Z Geburtshilfe Perinatol | year= 1985 | volume= 189 | issue= 5 | pages= 228-31 | pmid=4072318 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4072318  }} </ref><ref name="pmid3660970">{{cite journal| author=Esterl D, Rösel HD| title=[Multifocal (chaotic) atrial tachycardia in a newborn infant]. | journal=Zentralbl Gynakol | year= 1987 | volume= 109 | issue= 14 | pages= 919-22 | pmid=3660970 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3660970  }} </ref><ref name="pmid21267831">{{cite journal| author=Bouziri A, Khaldi A, Hamdi A, Ben Massoud I, Borgi A, Menif K | display-authors=etal| title=Multifocal atrial tachycardia: an unusual cause of cardiogenic shock in a newborn. | journal=Tunis Med | year= 2011 | volume= 89 | issue= 1 | pages= 59-61 | pmid=21267831 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21267831  }} </ref>
*[[Multifocal atrial tachycardia (MAT)|MAT]] is difficult to [[Treatments|treat]] in [[infancy]] but it [[Resolving power|resolves]] [[Frequentist|frequently]] and spontaneously within the first [[year]] of [[life]].<ref name="pmid6737948">{{cite journal| author=Toussaint R, Hofstetter R, von Bernuth G| title=[Multifocal atrial tachycardia in infancy]. | journal=Klin Padiatr | year= 1984 | volume= 196 | issue= 2 | pages= 118-20 | pmid=6737948 | doi=10.1055/s-2007-1025591 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6737948  }} </ref>
 
==Natural history, Complications and Prognosis==
*[[Multifocal atrial tachycardia (MAT)|Multifocal atrial tachycardia]] is considered to be a [[Relatively compact|relatively]] [[benign]] [[Cardiac arrhythmia|arrhythmia]] with [[Likelihood|likely]] good [[outcome]] in the absence of a severe [[Underlying representation|underlying]] [[illness]].
*[[Multifocal atrial tachycardia (MAT)|MAT]] can be [[WellPoint|well]] [[Control|controlled]] if [[Treatments|treated]] with [[Appropriate Use Criteria|appropriate]] [[drugs]] along with a suggested long follow-up [[period]].
*In the [[Case-based reasoning|case]] of a required [[pharmacologic]] [[Intervention (counseling)|intervention]], [[amiodarone]] is [[Suggestion|suggested]] as an excellent choice.<ref name="pmid17051756">{{cite journal| author=Hsieh MY, Lee PC, Hwang B, Meng CC| title=Multifocal atrial tachycardia in 2 children. | journal=J Chin Med Assoc | year= 2006 | volume= 69 | issue= 9 | pages= 439-43 | pmid=17051756 | doi=10.1016/S1726-4901(09)70288-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17051756  }} </ref>
*Baek et al [[Reporting results|reported]] in a [[Study design|study]] that:<ref name="pmid29441747">{{cite journal| author=Baek SM, Chung H, Song MK, Bae EJ, Kim GB, Noh CI| title=The Complexity of Pediatric Multifocal Atrial Tachycardia and Its Prognostic Factors. | journal=Korean Circ J | year= 2018 | volume= 48 | issue= 2 | pages= 148-158 | pmid=29441747 | doi=10.4070/kcj.2017.0179 | pmc=5861005 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29441747  }} </ref>
**Usually, [[Multifocal atrial tachycardia (MAT)|MAT]] [[Affect|affects]] [[infants]] with a favorable [[prognosis]] especially the [[idiopathic]] [[infant]] [[Group (periodic table)|group]].
**But in the [[Presenting symptom|presence]] of other [[comorbidities]] with [[Multifocal atrial tachycardia (MAT)|MAT]], it may have a [[variable]] [[clinical]] [[Course (medicine)|course]].
*Although most [[patients]] with [[Multifocal atrial tachycardia (MAT)|multifocal atrial tachycardia]] are [[hemodynamically]] [[Stability|stable]], still [[Multifocal atrial tachycardia (MAT)|MAT]] is a poor [[prognostic]] [[Sign (medicine)|sign]] in the [[Set|setting]] of an [[Acute (medicine)|acute]] [[illness]].
*[[Multifocal atrial tachycardia (MAT)|MAT]] is [[Association (statistics)|associated]] with a 60% in-[[hospital]] [[mortality rate]].
*The [[mean]] [[Survival rate|survival]] of [[patients]] with [[Multifocal atrial tachycardia (MAT)|MAT]] is just over one [[year]].<ref name="pmid30571060">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30571060 | doi= | pmc= | url= }} </ref><ref name="pmid30055033">{{cite journal| author=Levin MD, Saitta SC, Gripp KW, Wenger TL, Ganesh J, Kalish JM | display-authors=etal| title=Nonreentrant atrial tachycardia occurs independently of hypertrophic cardiomyopathy in RASopathy patients. | journal=Am J Med Genet A | year= 2018 | volume= 176 | issue= 8 | pages= 1711-1722 | pmid=30055033 | doi=10.1002/ajmg.a.38854 | pmc=6107379 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30055033  }} </ref>


==Diagnosis==
==Diagnosis==
The [[diagnosis]] of [[Multifocal atrial tachycardia (MAT)|MAT]] is usually not [[clinical]] rather the following [[electrocardiographic]] [[diagnostic criteria]] is used:
===Electrocardiography===
===Electrocardiography===
* There are [[P waves]] of varying morphology from at least three different foci
[[ECG]] of [[Multifocal atrial tachycardia (MAT)|MAT]] has following [[Characteristic impedance|characteristics]]:
* There is absence of one dominant atrial pacemaker
* Variable [[PP interval]]s, [[RR interval]]s, and [[PR interval]]s
* Atrial rate is above 100 beats per minute (bpm)
* Can be mistaken for [[atrial fibrillation]] if the [[p waves]] are of low amplitude
* High incidence in the elderly and in those with [[COPD]]
*Multifocal atrial tachycardia should be suspected in patients with tachycardia and irregularly irregular rhythm. Given its association with underlying medical conditions, it should also be suspected in patients with cardiac and pulmonary disease. Diagnosis is not clinical, but is made with electrocardiogram and can be made using the following diagnostic criteria. The electrocardiogram should show an atrial rate of greater than 100 beats per minute (although some suggest using a threshold of 90 beats per minute) with three or more discrete P wave morphologies in the same lead, not including that originating from the sinoatrial node. Furthermore, there should be irregular PP intervals, and the baseline should be isoelectric between P waves. Other findings that are commonly seen, but are not diagnostic include irregular PR and RR intervals. Variation in PR intervals has not been included in the diagnostic criteria because the PR interval varies with the length of the preceding RP interval.<ref name="pmid7652630">{{cite journal| author=van der Watt MJ, Aboo AA, Millar RN| title=A prospective study of electrical cardioversion for sustained tachycardias by emergency unit personnel. | journal=S Afr Med J | year= 1995 | volume= 85 | issue= 6 | pages= 508-11 | pmid=7652630 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7652630  }} </ref>
*A diagnosis of multifocal atrial tachycardia does not typically warrant any additional workup, other than workup required for any underlying conditions. However, if the arrhythmia persists despite treatment of underlying medical conditions it may be worth checking a complete blood count and serum chemistry for signs of infection, anemia, or electrolyte abnormalities such as hypokalemia and hypomagnesemia.
*Other diagnoses that may present with similar findings on electrocardiogram that should be included in the differential diagnosis include sinus tachycardia with frequent premature atrial contractions (this would have regular PP intervals), atrial flutter with variable AV node conduction (this would have regular PP intervals and flutter waves), atrial fibrillation (this would not have discrete P-wave morphologies), and wandering atrial pacemaker which would have a heart rate less than 100 beats per minute).
*For the pediatric practitioners, 4 issues have arisen from above studies regarding MAT in children as follows: 1) how to detect early, 2) how to control, 3) how deep to investigate etiologies of MAT, and 4) how to predict another arrhythmia and outcome.
*Firstly, early detection is very important to prevent worse outcome in infantile onset MAT. Tachycardia is usually first detected during the newborn period and incidental detection not based on clinical suspicion is rather high. Clinical suspicion of infantile onset of MAT is important for early detection. If tachycardia last long over several days without proper management, myocardial dysfunction can develop resulting in congestive heart failure. due to tachycardia-induced cardiomyopathy. So early detection and immediate proper management for tachyarrhythmias is necessary.
*Secondly, complete control of MAT is not easily achievable with combination of multiple antiarrhythmic medications, even in high-dose combinations. A more realistic treatment goal is initially reducing the percentage of MAT and achieving ventricular rate control. Various drugs have been used for the purpose, including beta blocker, digoxin, and amiodarone, but there is no data to support the superiority of any one approach.
*Thirdly, because of variety of etiology of MAT in children, delineation of etiology should be done to treat underlying problems and get better clinical outcome. Idiopathic infantile onset group shows a favorable outcome compared to the other groups including SHD and syndromic disease. RASopathy has been reported to be associated with high incidence of atrial arrhythmias.6),7) MAT in children should be checked the association of RASopathy and vice versa.<ref name="pmid21344638">{{cite journal| author=Lin AE, Alexander ME, Colan SD, Kerr B, Rauen KA, Noonan J | display-authors=etal| title=Clinical, pathological, and molecular analyses of cardiovascular abnormalities in Costello syndrome: a Ras/MAPK pathway syndrome. | journal=Am J Med Genet A | year= 2011 | volume= 155A | issue= 3 | pages= 486-507 | pmid=21344638 | doi=10.1002/ajmg.a.33857 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21344638  }} </ref>
*Fourthly, further lethal arrhythmias could not be predicted not only by MAT but also by additional studies. Atrial premature beats, atrial fibrillation (AF), or atrial flutter are known to accompany MAT in both adults and pediatric patients.5),6),8) MAT may be an early manifestation of CPVT and also additional findings of atrioventricular nodal reentrant tachycardia. Phenotypical progression of MAT into CPVT and an association between the RyR2 mutation and AF and ectopic atrial tachycardia have reported.6),9) MAT in young children may be the initial manifestation of a potentially life-threatening arrhythmia of CPVT. Therefore, non-infantile form of MAT with structurally normal hearts might need aggressive evaluations and close follow-up.<ref name="pmid11499730">{{cite journal| author=Bradley DJ, Fischbach PS, Law IH, Serwer GA, Dick M| title=The clinical course of multifocal atrial tachycardia in infants and children. | journal=J Am Coll Cardiol | year= 2001 | volume= 38 | issue= 2 | pages= 401-8 | pmid=11499730 | doi=10.1016/s0735-1097(01)01390-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11499730  }} </ref><ref name="pmid29441747">{{cite journal| author=Baek SM, Chung H, Song MK, Bae EJ, Kim GB, Noh CI| title=The Complexity of Pediatric Multifocal Atrial Tachycardia and Its Prognostic Factors. | journal=Korean Circ J | year= 2018 | volume= 48 | issue= 2 | pages= 148-158 | pmid=29441747 | doi=10.4070/kcj.2017.0179 | pmc=5861005 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29441747  }} </ref><ref name="pmid8916490">{{cite journal| author=Fish FA, Mehta AV, Johns JA| title=Characteristics and management of chaotic atrial tachycardia of infancy. | journal=Am J Cardiol | year= 1996 | volume= 78 | issue= 9 | pages= 1052-5 | pmid=8916490 | doi=10.1016/s0002-9149(96)00536-x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8916490  }} </ref><ref name="pmid28237968">{{cite journal| author=Broendberg AK, Nielsen JC, Bjerre J, Pedersen LN, Kristensen J, Henriksen FL | display-authors=etal| title=Nationwide experience of catecholaminergic polymorphic ventricular tachycardia caused by RyR2 mutations. | journal=Heart | year= 2017 | volume= 103 | issue= 12 | pages= 901-909 | pmid=28237968 | doi=10.1136/heartjnl-2016-310509 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28237968  }} </ref>


==History and Symptoms==
*[[Atrial]] [[rate]] of greater than 100 [[beats per minute]] (although some also [[Suggestion|suggest]] a [[Threshold model|threshold]] of 90 [[beats per minute]] for [[Multifocal atrial tachycardia (MAT)|MAT]] [[diagnosis]])
*Multifocal atrial tachycardia is most often asymptomatic. However, patients typically have symptoms related to their underlying condition. Therefore, this arrhythmia is often found incidentally on the routine electrocardiogram. Studies show most people do not report palpitations or symptoms of syncope or pre-syncope. Once a diagnosis is made, a thorough history should be obtained with a focus on commonly associated conditions including cardiac and pulmonary diseases.
*[[Irregularly irregular pulse|Irregularly irregular]] [[rhythm]]
*There are [[P waves]] of [[Variable|varying]] [[Morphology (biology)|morphology]] from at least three [[Differentiate|different]] [[Focusing|foci]].
* There is an absence of one [[dominant]] [[atrial]] [[pacemaker]].
*[[Variable]] or irregular [[PP interval]]s, [[RR interval]]s, and [[PR interval]]s (however, [[Variable|variation]] in [[PR intervals]] is not yet included in the [[diagnostic criteria]] because of the [[Variable|variation]] of [[PR interval]] [[Dependent variable|depends]] on the [[length]] of the preceding [[RP]] [[Interval (mathematics)|interval]]).<ref name="pmid7652630">{{cite journal| author=van der Watt MJ, Aboo AA, Millar RN| title=A prospective study of electrical cardioversion for sustained tachycardias by emergency unit personnel. | journal=S Afr Med J | year= 1995 | volume= 85 | issue= 6 | pages= 508-11 | pmid=7652630 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7652630  }} </ref>
* Can be mistaken for [[atrial fibrillation]] if the [[p waves]] are of low [[amplitude]].
===Other diagnostic workup===
*As [[Multifocal atrial tachycardia (MAT)|multifocal atrial tachycardia]] is mostly [[Association (statistics)|associated]] with the [[Underlying representation|underlying]] [[medical conditions]] such as [[Cardiac disease|cardiac]] and [[pulmonary disease]], so its [[diagnosis]] does not [[Typical set|typically]] warrant any [[Addition reaction|additional]] workup, other than the workup required for the suspected [[Underlying representation|underlying]] [[conditions]].
*If the [[Cardiac arrhythmia|arrhythmia]] persists despite of [[Treatments|treating]] the [[Underlying representation|underlying]] [[medical conditions]], following [[Test|tests]] should be [[done]] to [[check]] for any [[signs]] of [[infection]], [[anemia]], or [[electrolyte abnormalities]] such as [[hypokalemia]] and [[hypomagnesemia]]:
**[[Complete blood count]]
**[[Serum]] [[chemistry]] [[Panel study|panel]]


==Physical Examination==
===Challenges in MAT pediatric patients===
*On physical exam, most patients will have an elevated heart rate and an irregularly irregular rhythm. Most patients are hemodynamically stable, however, due to the association with underlying conditions, it is sensible to conduct a general assessment for signs of cardiopulmonary disease, especially since this arrhythmia can trigger decompensation of underlying cardiac and pulmonary disease.
*[[Pediatric]] practitioners usually [[face]] the following four challenges regarding [[Multifocal atrial tachycardia (MAT)|MAT]] in [[children]]:
 
{| class="wikitable"
|+Challenges faced by pediatric practitioners while treating children with multifocal atrial tachycardia
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Challenges}}
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Details}}
|-
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''How to [[Detection theory|detect]] [[Multifocal atrial tachycardia (MAT)|MAT]] early'''
|
* Early [[Detection theory|detection]] of [[Multifocal atrial tachycardia (MAT)|MAT]] is very [[Importance sampling|important]] in [[Order (biology)|order]] to [[Prevention (medical)|prevent]] the worse [[outcome]] in the [[Case-based reasoning|case]] of [[Infant|infantile]]-onset [[Multifocal atrial tachycardia (MAT)|MAT]].
*Usually, [[tachycardia]] is first [[Detection theory|detected]] during the [[newborn]] [[period]] and the [[Incidental finding|incidental]] [[Detection theory|detection]] of [[Multifocal atrial tachycardia (MAT)|MAT]] not [[Base|based]] on the [[clinical]] suspicion is rather high.
*[[Clinical]] suspicion of the [[Infant|infantile]]-onset of [[Multifocal atrial tachycardia (MAT)|MAT]] is very [[Importance sampling|important]] for its early [[Detection theory|detection]].
*[[Multifocal atrial tachycardia (MAT)|MAT]] lasting longer over several days without any proper [[Managed care|management]] can [[lead]] to [[myocardial]] [[dysfunction]] which can further [[Causes|cause]] [[congestive heart failure]] due to [[tachycardia-induced cardiomyopathy]].
*Hence, it is [[Necessary and sufficient|necessary]] to [[Detection theory|detect]] [[Multifocal atrial tachycardia (MAT)|MAT]] early and immediately [[Treatments|treat]] it with [[Appropriate Use Criteria|appropriate]] [[Managed care|management]] to [[Prevention (medical)|prevent]] [[Congestive heart failure|CHF]].
|-
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''How to [[control]] [[Multifocal atrial tachycardia (MAT)|MAT]]'''
|
* Complete [[control]] of the [[Multifocal atrial tachycardia (MAT)|MAT]] is not easily achievable even with high-[[dose]] [[Combination therapy|combinations]] of multiple [[antiarrhythmic medications]].
* A more realistic [[Treatments|treatment]] [[Goal-directed therapy|goal]] is to initially [[Reduced|reduce]] the [[percentage]] of [[Multifocal atrial tachycardia (MAT)|MAT]] by [[Achievement test|achieving]] [[ventricular]] [[rate]] [[control]]. Various [[drugs]] such as [[beta-blockers]], [[digoxin]], and [[amiodarone]] have been [[Usage analysis|used]] for the purpose, but there is not enough [[data]] to [[support]] the [[Superiority complex|superiority]] of any one of these approaches.
|-
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''How deep to [[Investigational product|investigate]] [[etiologies]] of [[Multifocal atrial tachycardia (MAT)|MAT]]<ref name="pmid21344638">{{cite journal| author=Lin AE, Alexander ME, Colan SD, Kerr B, Rauen KA, Noonan J | display-authors=etal| title=Clinical, pathological, and molecular analyses of cardiovascular abnormalities in Costello syndrome: a Ras/MAPK pathway syndrome. | journal=Am J Med Genet A | year= 2011 | volume= 155A | issue= 3 | pages= 486-507 | pmid=21344638 | doi=10.1002/ajmg.a.33857 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21344638  }} </ref>'''
|
* As there are many varieties of [[etiologies]] of [[Multifocal atrial tachycardia (MAT)|MAT]] in [[children]], these [[etiologies]] should be [[Description logic|described]] in [[Detailed balance|detail]] in [[Order (biology)|order]] to [[Treatments|treat]] the [[Underlying representation|underlying]] [[Problem Solved|problems]] and get a better [[clinical]] [[outcome]].
*[[Idiopathic]] [[Infant|infantile]]-onset [[Group (periodic table)|group]] shows a favorable [[outcome]] [[Comparability|compared]] to the other [[Group (periodic table)|groups]] such as [[Syndrome|syndromic]] [[disease]].
*RASopathy has been [[Reporting results|reported]] to be [[Association (statistics)|associated]] with a high [[incidence]] of [[atrial arrhythmias]] hence, [[Multifocal atrial tachycardia (MAT)|MAT]] in [[children]] should be [[Check|checked]] for the [[Association (statistics)|association]] of RASopathy and vice versa.
|-
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |How to [[Prediction|predict]] another [[Cardiac arrhythmia|arrhythmia]] and [[outcome]]<ref name="pmid11499730" /><ref name="pmid29441747" /><ref name="pmid8916490">{{cite journal| author=Fish FA, Mehta AV, Johns JA| title=Characteristics and management of chaotic atrial tachycardia of infancy. | journal=Am J Cardiol | year= 1996 | volume= 78 | issue= 9 | pages= 1052-5 | pmid=8916490 | doi=10.1016/s0002-9149(96)00536-x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8916490  }} </ref><ref name="pmid28237968">{{cite journal| author=Broendberg AK, Nielsen JC, Bjerre J, Pedersen LN, Kristensen J, Henriksen FL | display-authors=etal| title=Nationwide experience of catecholaminergic polymorphic ventricular tachycardia caused by RyR2 mutations. | journal=Heart | year= 2017 | volume= 103 | issue= 12 | pages= 901-909 | pmid=28237968 | doi=10.1136/heartjnl-2016-310509 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28237968  }} </ref>
|
*[[Atrial premature beats]], [[atrial fibrillation]] ([[Atrial fibrillation|AF]]), or [[atrial flutter]] are known to accompany [[Multifocal atrial tachycardia (MAT)|MAT]] in both [[Adult|adults]] and [[pediatric]] [[patients]].
*[[Multifocal atrial tachycardia (MAT)|MAT]] may be an early [[Presenting symptom|manifestation]] of [[catecholaminergic polymorphic ventricular tachycardia]] ([[Catecholaminergic polymorphic ventricular tachycardia|CPVT]]) with additional findings of [[atrioventricular nodal reentrant tachycardia]].
*[[Phenotypical]] progression of [[Multifocal atrial tachycardia (MAT)|MAT]] into [[Catecholaminergic polymorphic ventricular tachycardia|CPVT]] and an [[Association (statistics)|association]] between the RyR2 [[mutation]] and [[Atrial fibrillation|AF]] and [[ectopic]] [[atrial tachycardia]] have been [[Reporting results|reported]].
*[[Multifocal atrial tachycardia (MAT)|MAT]] in young [[children]] may be the initial [[Presenting symptom|manifestation]] of a potentially [[life]]-threatening [[Cardiac arrhythmia|arrhythmia]] of [[Catecholaminergic polymorphic ventricular tachycardia|CPVT]]. Hence, aggressive evaluations and close follow-ups might be required for the non-[[Infant|infantile]] form of [[Multifocal atrial tachycardia (MAT)|MAT]] with [[Structure factor|a structurally]] [[normal]] [[Heart|heart.]]
|}
 
===History and Symptoms===
*Mostly [[patients]] with [[Multifocal atrial tachycardia (MAT)|multifocal atrial tachycardia]] are [[asymptomatic]].
*[[Multifocal atrial tachycardia (MAT)|MAT]] is often [[Incidental finding|incidentally found]] during the routine [[electrocardiogram]].
*Once the [[diagnosis]] of [[Multifocal atrial tachycardia (MAT)|MAT]] is made, a thorough [[History and Physical examination|history]] should be obtained with [[Main effect|main]] [[Focusing|focus]] on commonly [[Association (statistics)|associated]] [[conditions]] such as [[cardiac]] and [[Pulmonary disease|pulmonary diseases]] particularly [[congestive heart failure]] and [[chronic obstructive pulmonary disease]] respectively.
*The [[clinical]] [[Presenting symptoms|manifestations]] of [[Multifocal atrial tachycardia (MAT)|MAT]] [[Difference (philosophy)|differ]] from those of other [[tachyarrhythmias]] in that [[symptoms]] predominantly [[relate]] to the [[Underlying representation|underlying]] [[Precipitation (chemistry)|precipitating]] [[illness]] rather than the [[Cardiac arrhythmia|arrhythmia]] itself.
*[[Patients]] usually [[Presenting symptoms|present]] with:
**[[Irregular heart rhythms|Irregular]] [[heart rate]] greater than 100 [[beats per minute]] (mostly [[Identity (social science)|identified]] only during the [[physical examination]] by the [[health care provider]])
**[[Palpitations]] ([[rare]])
**[[Presyncope]] ([[rare]])
**[[Syncope (medicine)|Syncope]] ([[rare]])
*[[Picture thinking|Picture]] of a [[Typical set|typical]] [[Multifocal atrial tachycardia (MAT)|MAT]] [[patient]] is as follows:<ref name="pmid2188131">{{cite journal| author=Kastor JA| title=Multifocal atrial tachycardia. | journal=N Engl J Med | year= 1990 | volume= 322 | issue= 24 | pages= 1713-7 | pmid=2188131 | doi=10.1056/NEJM199006143222405 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2188131  }} </ref><ref name="pmid5662166">{{cite journal| author=Shine KI, Kastor JA, Yurchak PM| title=Multifocal atrial tachycardia. Clinical and electrocardiographic features in 32 patients. | journal=N Engl J Med | year= 1968 | volume= 279 | issue= 7 | pages= 344-9 | pmid=5662166 | doi=10.1056/NEJM196808152790703 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5662166  }} </ref>
**[[Elderly]] [[patient]]
**[[Decompensation|Decompensated]] [[pulmonary disease]]
**[[Decompensated heart failure]]
** Postoperative
** Usually [[hemodynamically]] [[Stability|stable]] (no severe [[hemodynamic compromise]] [[Association (statistics)|associated]] with [[Multifocal atrial tachycardia (MAT)|MAT]])
* High [[mortality]] [[ECG]] [[Features (pattern recognition)|features]] in [[Multifocal atrial tachycardia (MAT)|MAT]] [[patients]] include:
**[[P waves]] with ≥3 forms
**[[Atrial]] [[rate]] usually 100 to 200 [[Beats per minute|bpm]]
**[[Irregular heart rhythms|Irregular]] [[atrial]] [[rate]]
**[[Variable]] [[PR interval]]
**[[Isoelectric point|Isoelectric]] [[Baseline (medicine)|baseline]] between [[P waves]]
** May progress to [[atrial fibrillation]]
 
===Physical Examination===
*[[Physical examination]] findings of [[patients]] with [[Multifocal atrial tachycardia (MAT)|multifocal atrial tachycardia]] include:
**[[Elevated heart rate]] usually greater than 100 [[Beats per minute|bpm]]
**[[Irregularly irregular pulse|Irregularly irregular]] [[rhythm]]
**[[Hemodynamically]] [[Stability|stable]] (mostly)
*As [[Multifocal atrial tachycardia (MAT)|MAT]] is [[Association (statistics)|associated]] with [[Underlying representation|underlying]] [[medical conditions]], hence, it is [[Suggestion|suggested]] to [[Carrying capacity|carry]] out a [[Generalization|general]] [[Assessment and Plan|assessment]] for the [[signs]] of [[cardiopulmonary]] [[disease]], especially because [[Multifocal atrial tachycardia (MAT)|MAT]] can [[trigger]]  the [[decompensation]] of [[Underlying representation|underlying]] [[cardiac]] and [[pulmonary disease]].


==Treatment==
==Treatment==
*Combined flecainide and sotalol therapy for multifocal atrial tachycardia in cardio-facio-cutaneous syndrome.<ref name="pmid30536490">{{cite journal| author=Sakurai K, Takahashi K, Nakayashiro M| title=Combined flecainide and sotalol therapy for multifocal atrial tachycardia in cardio-facio-cutaneous syndrome. | journal=Pediatr Int | year= 2018 | volume= 60 | issue= 11 | pages= 1036-1037 | pmid=30536490 | doi=10.1111/ped.13695 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30536490  }} </ref><ref name="pmid8916490">{{cite journal| author=Fish FA, Mehta AV, Johns JA| title=Characteristics and management of chaotic atrial tachycardia of infancy. | journal=Am J Cardiol | year= 1996 | volume= 78 | issue= 9 | pages= 1052-5 | pmid=8916490 | doi=10.1016/s0002-9149(96)00536-x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8916490  }} </ref>
{| class="wikitable"
*Successful treatment with Ibutilide is demonstrated. Treatment with a class III antiarrhythmic agent opposes the frequently accepted mechanism of triggered activity in causing this arrhythmia.<ref name="pmid11455238">{{cite journal| author=Pierce WJ, McGroary K| title=Multifocal atrial tachycardia and Ibutilide. | journal=Am J Geriatr Cardiol | year= 2001 | volume= 10 | issue= 4 | pages= 193-5 | pmid=11455238 | doi=10.1111/j.1076-7460.2001.00016.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11455238 }} </ref>
|+
*The treatment of multifocal atrial tachycardia should focus on treating underlying medical conditions. Most episodes of multifocal atrial tachycardia resolve with treatment of underlying conditions. Specific treatment is indicated if the patient develops symptomatic decompensation of their underlying cardiac or pulmonary disease or in the rare setting of persistent symptomatic arrhythmia despite adequate treatment of underlying conditions. If treatment is indicated, therapy should begin with first correcting underlying electrolyte abnormalities with repletion of potassium or magnesium. Studies have shown magnesium suppresses ectopic atrial activity and can be beneficial even if magnesium levels are within the normal range. Once electrolyte abnormalities have been corrected, possible treatment options include non-dihydropyridine calcium channel blockers, beta-blockers, and atrioventricular (AV) node ablation. Studies have found no role for antiarrhythmic agents, cardioversion, or anticoagulation.
Treatment options for multifocal atrial tachycardia
*In the absence of underlying pulmonary disease, the first line agent is beta blockers. Beta blockers act to suppress ectopic foci by reducing sympathetic stimulation and decreasing conduction through the atrioventricular node, thereby slowing the ventricular response.  Studies have found an average decrease in heart rate of 51 beats per minute and 79% of patients reverted to sinus rhythm. Most patients did not need beta-blocker therapy long term as studies found long-term therapy was needed in only 25% of patients. Caution should be used in patients with an underlying pulmonary disease such as COPD and patients with decompensated heart failure due to the increased risk for bronchospasms and decreased cardiac output. Furthermore, beta-blockers should be avoided in patients with atrioventricular blocks unless a pacemaker has been implanted.
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Treatment option}}
*In the presence of underlying pulmonary disease, the first line agent is non-dihydropyridine calcium channel blocker such as verapamil or diltiazem. These agents act to suppress atrial rate and decrease conduction through the atrioventricular node, thereby slowing the ventricular rate. Studies have found an average reduction in the ventricular rate of 31 beats per minute and 43% of patients reverted to sinus rhythm. Caution should be used in patients with preexisting heart failure or hypotension due to negative inotropic effects and peripheral vasodilation.  Similarly, calcium channel blockers should also be avoided in patients with atrioventricular blocks unless a pacemaker has been implanted.
! style="background: #4479BA; width: 200px;" | {{fontcolor|#FFF|Description}}
*In select cases of refractory multifocal atrial tachycardia, AV node ablation has been performed. Studies have found an average reduction in the ventricular rate of 56 beats per minute with adequate control of ventricular response in 84% of patients. However, AV node ablation creates a complete heart block and requires placement of a permanent pacemaker.
|-
*MAT is best managed by an interprofessional team, including cardiology nurses. In general, MAT is benign and usually resolved if the offending agent or disease is managedTherapies that have not been found to have a role in the treatment of multifocal atrial tachycardia include antiarrhythmics, cardioversion, or anticoagulation. Studies have found most cases of multifocal atrial tachycardia will resolve without specific antiarrhythmic therapy. Antiarrhythmics such as quinidine, procainamide, lidocaine, and phenytoin have yet to be proven successful. Furthermore, digitalis has also not been shown to have any benefit. Cardioversion has not been shown to be effective in converting to sinus rhythm and should not be used in the treatment of multifocal atrial tachycardia. While one study found 55% of patients with multifocal atrial tachycardia developed atrial fibrillation or atrial flutter, current guidelines do not support the use of anticoagulation.<ref name="pmid29441747">{{cite journal| author=Baek SM, Chung H, Song MK, Bae EJ, Kim GB, Noh CI| title=The Complexity of Pediatric Multifocal Atrial Tachycardia and Its Prognostic Factors. | journal=Korean Circ J | year= 2018 | volume= 48 | issue= 2 | pages= 148-158 | pmid=29441747 | doi=10.4070/kcj.2017.0179 | pmc=5861005 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29441747 }} </ref><ref name="pmid21621374">{{cite journal| author=Kantoch MJ, Gulamhusein SS, Sanatani S| title=Short- and long-term outcomes in children undergoing radiofrequency catheter ablation before their second birthday. | journal=Can J Cardiol | year= 2011 | volume= 27 | issue= 4 | pages= 523.e3-9 | pmid=21621374 | doi=10.1016/j.cjca.2010.12.043 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21621374 }} </ref><ref name="pmid18557136">{{cite journal| author=Ho KM| title=Intravenous magnesium for cardiac arrhythmias: jack of all trades. | journal=Magnes Res | year= 2008 | volume= 21 | issue= 1 | pages= 65-8 | pmid=18557136 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18557136 }} </ref>
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Treatments|Treat]] [[Underlying representation|underlying]] [[medical condition]]
*intramuscular and continuous intravenous magnesium sulphate regimens used in pre-eclampsia. Both routes of administration were successful in causing reversion to sinus rhythm but the intramuscular regimen, by attaining a higher and more sustained serum magnesium concentration, converted the arrhythmia to normal sinus rhythm in a shorter period of time (1-2 hours) than the intravenous regimen (4-8 hours).Intravenous magnesium sulfate is superior to amiodarone in the conversion of acute atrial tachyarrhythmias, while initial slowing of ventricular response rate in nonconverters appears equally efficacious with both agents.<ref name="pmid3275209">{{cite journal| author=Cohen L, Kitzes R, Shnaider H| title=Multifocal atrial tachycardia responsive to parenteral magnesium. | journal=Magnes Res | year= 1988 | volume= 1 | issue= 3-4 | pages= 239-42 | pmid=3275209 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3275209  }} </ref><ref name="pmid4050650">{{cite journal| author=Iseri LT, Fairshter RD, Hardemann JL, Brodsky MA| title=Magnesium and potassium therapy in multifocal atrial tachycardia. | journal=Am Heart J | year= 1985 | volume= 110 | issue= 4 | pages= 789-94 | pmid=4050650 | doi=10.1016/0002-8703(85)90458-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4050650  }} </ref><ref name="pmid7587256">{{cite journal| author=Moran JL, Gallagher J, Peake SL, Cunningham DN, Salagaras M, Leppard P| title=Parenteral magnesium sulfate versus amiodarone in the therapy of atrial tachyarrhythmias: a prospective, randomized study. | journal=Crit Care Med | year= 1995 | volume= 23 | issue= 11 | pages= 1816-24 | pmid=7587256 | doi=10.1097/00003246-199511000-00005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7587256  }} </ref><ref name="pmid18557136">{{cite journal| author=Ho KM| title=Intravenous magnesium for cardiac arrhythmias: jack of all trades. | journal=Magnes Res | year= 2008 | volume= 21 | issue= 1 | pages= 65-8 | pmid=18557136 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18557136  }} </ref><ref name="pmid11105328">{{cite journal| author=Stühlinger HG, Kiss K, Smetana R| title=[Significance of magnesium in cardiac arrhythmias]. | journal=Wien Med Wochenschr | year= 2000 | volume= 150 | issue= 15-16 | pages= 330-4 | pmid=11105328 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11105328  }} </ref><ref name="pmid9064958">{{cite journal| author=Zehender M| title=[Magnesium as an anti-arrhythmic therapy principle in supraventricular and ventricular cardiac arrhythmias]. | journal=Z Kardiol | year= 1996 | volume= 85 Suppl 6 | issue=  | pages= 135-45 | pmid=9064958 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9064958  }} </ref><ref name="pmid9333591">{{cite journal| author=Vester EG| title=[Clinico-electrophysiologic effects of magnesium, especially in supraventricular tachycardia]. | journal=Herz | year= 1997 | volume= 22 Suppl 1 | issue=  | pages= 40-50 | pmid=9333591 | doi=10.1007/bf03042654 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9333591  }} </ref>
|
*Parentral potassium, We believe that serum magnesium administered together with serum potassium stabilizes the ionic balance of atrial cells and thus prevents spontaneous ectopy.<ref name="pmid4050650">{{cite journal| author=Iseri LT, Fairshter RD, Hardemann JL, Brodsky MA| title=Magnesium and potassium therapy in multifocal atrial tachycardia. | journal=Am Heart J | year= 1985 | volume= 110 | issue= 4 | pages= 789-94 | pmid=4050650 | doi=10.1016/0002-8703(85)90458-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4050650  }} </ref>
* The [[Treatments|treatment]] of [[Multifocal atrial tachycardia (MAT)|multifocal atrial tachycardia]] should be [[Focusing|focused]] on [[Treatments|treating]] the [[Underlying representation|underlying]] [[medical conditions]] as most episodes of the [[Multifocal atrial tachycardia (MAT)|MAT]] [[Resolution|resolve]] with the [[Treatments|treatment]] of [[Underlying representation|underlying]] [[conditions]].
* Specific [[Treatments|treatment]] of [[Multifocal atrial tachycardia (MAT)|MAT]] is [[Indication (medicine)|indicated]] if the [[patient]] [[Development|develops]] [[symptomatic]] [[decompensation]] of their [[Underlying representation|underlying]] [[cardiac]] or [[pulmonary disease]] or in the [[rare]] [[Set|setting]] of persistent [[symptomatic]] [[Cardiac arrhythmia|arrhythmia]] despite [[Adequate stimulus|adequate]] [[Treatments|treatment]] of [[Underlying representation|underlying]] [[conditions]].
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Magnesium]] repletion<ref name="pmid3275209">{{cite journal| author=Cohen L, Kitzes R, Shnaider H| title=Multifocal atrial tachycardia responsive to parenteral magnesium. | journal=Magnes Res | year= 1988 | volume= 1 | issue= 3-4 | pages= 239-42 | pmid=3275209 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3275209 }} </ref><ref name="pmid4050650">{{cite journal| author=Iseri LT, Fairshter RD, Hardemann JL, Brodsky MA| title=Magnesium and potassium therapy in multifocal atrial tachycardia. | journal=Am Heart J | year= 1985 | volume= 110 | issue= 4 | pages= 789-94 | pmid=4050650 | doi=10.1016/0002-8703(85)90458-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4050650  }} </ref><ref name="pmid7587256">{{cite journal| author=Moran JL, Gallagher J, Peake SL, Cunningham DN, Salagaras M, Leppard P| title=Parenteral magnesium sulfate versus amiodarone in the therapy of atrial tachyarrhythmias: a prospective, randomized study. | journal=Crit Care Med | year= 1995 | volume= 23 | issue= 11 | pages= 1816-24 | pmid=7587256 | doi=10.1097/00003246-199511000-00005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7587256  }} </ref><ref name="pmid18557136">{{cite journal| author=Ho KM| title=Intravenous magnesium for cardiac arrhythmias: jack of all trades. | journal=Magnes Res | year= 2008 | volume= 21 | issue= 1 | pages= 65-8 | pmid=18557136 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18557136 }} </ref><ref name="pmid11105328">{{cite journal| author=Stühlinger HG, Kiss K, Smetana R| title=[Significance of magnesium in cardiac arrhythmias]. | journal=Wien Med Wochenschr | year= 2000 | volume= 150 | issue= 15-16 | pages= 330-4 | pmid=11105328 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11105328  }} </ref><ref name="pmid9064958">{{cite journal| author=Zehender M| title=[Magnesium as an anti-arrhythmic therapy principle in supraventricular and ventricular cardiac arrhythmias]. | journal=Z Kardiol | year= 1996 | volume= 85 Suppl 6 | issue= | pages= 135-45 | pmid=9064958 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9064958 }} </ref><ref name="pmid9333591">{{cite journal| author=Vester EG| title=[Clinico-electrophysiologic effects of magnesium, especially in supraventricular tachycardia]. | journal=Herz | year= 1997 | volume= 22 Suppl 1 | issue= | pages= 40-50 | pmid=9333591 | doi=10.1007/bf03042654 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9333591 }} </ref><ref name="pmid29441747" /><ref name="pmid21621374">{{cite journal| author=Kantoch MJ, Gulamhusein SS, Sanatani S| title=Short- and long-term outcomes in children undergoing radiofrequency catheter ablation before their second birthday. | journal=Can J Cardiol | year= 2011 | volume= 27 | issue= 4 | pages= 523.e3-9 | pmid=21621374 | doi=10.1016/j.cjca.2010.12.043 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21621374 }} </ref><ref name="pmid18557136" />
|
* If [[Treatments|treatment]] is [[Indication (medicine)|indicated]] in a [[Multifocal atrial tachycardia (MAT)|MAT]] [[patient]], [[therapy]] should first start with [[Correction (newspaper)|correcting]] any [[Underlying representation|underlying]] [[electrolyte abnormalities]] with the repletion of [[potassium]] or [[magnesium]].
* According to [[Study design|studies]], [[magnesium]] [[Suppression (eye)|suppresses]] [[ectopic]] [[atrial]] [[Activity (chemistry)|activity]], and thus, can be beneficial even if [[magnesium]] [[Leveling effect|levels]] are within the [[normal]] [[Range (statistics)|range]].
 
*[[Intramuscular]] and [[Continuous function|continuous]] [[intravenous]] [[magnesium sulfate]] regimens [[Usage analysis|used]] in [[pre-eclampsia]] can be [[Usage analysis|used]] for [[Multifocal atrial tachycardia (MAT)|MAT]] [[Treatments|treatment]].
*Both [[routes of administration]] are proven to be successful in [[Causes|causing]] [[Reverse learning|reversion]] to [[sinus rhythm]].
*However, a [[Higher Power|higher]] and more [[Sustainable|sustained]] [[serum]] [[magnesium]] [[concentration]] can be attained by the [[intramuscular]] regimen, [[Lead|leading]] to the [[Conversion (logic)|conversion]] of [[Multifocal atrial tachycardia (MAT)|MAT]] [[Association (statistics)|associated]] [[Cardiac arrhythmia|arrhythmia]] to [[normal sinus rhythm]] in a shorter [[period]] of [[Time series|time]] (1-2 hours) as [[Comparability|compared]] to the [[Intravenous therapy|intravenous regimen]] (4-8 hours).
*[[Intravenous]] [[magnesium sulfate]] is considered to be [[superior]] to [[amiodarone]] in the [[Conversion (logic)|conversion]] of [[Acute (medicine)|acute]] [[atrial tachyarrhythmias]], while [[Initial dropping|initial]] [[Slow|slowing]] of [[ventricular]] [[response rate]] in nonconverters [[Appearance|appears]] to be [[Equalism|equally]] [[efficacious]] with both [[Agent study|agents]].
 
<br />
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |[[Potassium]] repletion<ref name="pmid4050650" />
|
*[[Parenteral]] [[potassium]] administered together with [[serum]] [[magnesium]] [[Stabilization (medicine)|stabilizes]] the [[Ionic bond|ionic]] [[Balance disorder|balance]] of [[atrial]] [[Cells (biology)|cells]] and thus [[Prevention (medical)|prevents]] spontaneous [[Ectopic|ectopy]].
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Non-dihydropyridine calcium channel blocker|Non-dihydropyridine calcium channel blockers]]'''
|
* Once all the [[electrolyte abnormalities]] have been [[Corrective|corrected]], [[Possibility theory|possible]] [[Treatments|treatment]] options include [[Non-dihydropyridine calcium channel blocker|non-dihydropyridine calcium channel blockers]].
* If the [[Multifocal atrial tachycardia (MAT)|MAT]] [[patient]] has an [[Underlying representation|underlying]] [[pulmonary disease]], the [[First-line treatment|first-line agent]] is a [[non-dihydropyridine calcium channel blocker]] such as [[verapamil]] or [[diltiazem]].
* These [[drugs]] [[Suppression (eye)|suppress]] the [[atrial]] [[rate]] and decrease [[Conduction System|conduction]] through the [[atrioventricular node]] thus, [[Slow|slowing]] the [[ventricular]] [[rate]], with an [[average]] [[reduction]] in the [[ventricular]] [[rate]] of 31 [[beats per minute]] and reversion of 43% of the [[Multifocal atrial tachycardia (MAT)|MAT]] [[patients]] to [[normal sinus rhythm]].
*[[Calcium channel blockers]] ([[Calcium channel blocker|CCB]]) should be [[Usage analysis|used]] with caution in [[patients]] with preexisting [[heart failure]] or [[hypotension]] due to negative [[inotropic]] [[Effect size|effects]] and peripheral [[vasodilation]].
*[[Calcium channel blocker|CCB]] should also be [[Avoidance response|avoided]] in [[patients]] with [[Atrioventricular block|atrioventricular blocks]] unless a [[pacemaker]] has already been [[Implanted pacemaker|implanted]].
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Beta blockers]]'''
|
*[[Beta-blockers]] are the [[First-line treatment|first-line agents]] in the [[Treatments|treatment]] of [[Multifocal atrial tachycardia (MAT)|MAT]] [[patients]] with no [[Underlying representation|underlying]] [[pulmonary disease]].
*[[Beta-blockers]] act by [[Suppression (eye)|suppressing]] the [[ectopic]] [[Focus (optics)|foci]] and thus, [[Reduced|reduce]] the [[Sympathetic nervous system|sympathetic]] [[Stimulated emission|stimulation]] [[Lead|leading]] to a decrease in [[Conduction System|conduction]] through the [[atrioventricular node]], ultimately [[Slow|slowing]] the [[ventricular]] [[Response element|response]].
* They [[Causes|cause]] an [[average]] decrease in [[heart rate]] of 51 [[beats per minute]] and [[Reversal potential|reversion]] of 79% of the [[Multifocal atrial tachycardia (MAT)|MAT]] [[patients]] to [[normal sinus rhythm]].
* Only 20% of the [[Multifocal atrial tachycardia (MAT)|MAT]] [[patients]] require long-term [[therapy]] with [[beta-blockers]].
*[[Beta-blockers]] should be [[Usage analysis|used]] with caution in [[patients]] with an [[Underlying representation|underlying]] [[pulmonary disease]] such as [[Chronic obstructive pulmonary disease|COPD]] and [[decompensated heart failure]] due to an increased [[RiskMetrics|risk]] for [[bronchospasm]] and decreased [[cardiac output]].
*[[Beta-blockers]] should be [[Avoidance response|avoided]] in [[patients]] with [[atrioventricular]] blocks unless a [[pacemaker]] has already been [[Implanted pacemaker|implanted]].
|-
| style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Antiarrhythmic drugs]]<ref name="pmid30536490">{{cite journal| author=Sakurai K, Takahashi K, Nakayashiro M| title=Combined flecainide and sotalol therapy for multifocal atrial tachycardia in cardio-facio-cutaneous syndrome. | journal=Pediatr Int | year= 2018 | volume= 60 | issue= 11 | pages= 1036-1037 | pmid=30536490 | doi=10.1111/ped.13695 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=30536490  }} </ref><ref name="pmid8916490" /><ref name="pmid11455238">{{cite journal| author=Pierce WJ, McGroary K| title=Multifocal atrial tachycardia and Ibutilide. | journal=Am J Geriatr Cardiol | year= 2001 | volume= 10 | issue= 4 | pages= 193-5 | pmid=11455238 | doi=10.1111/j.1076-7460.2001.00016.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11455238  }} </ref>'''
|
*[[Combination therapy|Combined]] [[flecainide]] and [[sotalol]] [[therapy]] is [[Proof|proven]] [[efficacious]] for [[Multifocal atrial tachycardia (MAT)|multifocal atrial tachycardia]] [[patients]] with the [[cardio]]-[[Facial|facio]]-[[cutaneous]] [[syndrome]].
*The successful [[Treatments|treatment]] of [[Multifocal atrial tachycardia (MAT)|MAT]] with [[ibutilide]] is also demonstrated.
*[[Treatments|Treatment]] with a [[Class (biology)|Class]] III [[antiarrhythmic agent]] opposes the [[Frequentist|frequently]] [[Acceptor|accepted]] [[Mechanism (biology)|mechanism]] of [[Trigger|triggered]] [[Activity (chemistry)|activity]] in [[Causes|causing]] this [[Cardiac arrhythmia|arrhythmia]].
*[[Antiarrhythmics]] such as [[quinidine]], [[procainamide]], [[lidocaine]], and [[phenytoin]] are not yet [[Proof|proven]] successful.
*[[Digitalis]] has also not been [[Proof|proven]] to be beneficial in [[Multifocal atrial tachycardia (MAT)|MAT]] [[Treatments|treatment]].
|-
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Radiofrequency ablation|Radiofrequency]] [[AV nodal ablation]]'''
|
* In a [[Fewmets|few]] [[Selection|selected]] [[Case-based reasoning|cases]] of [[refractory]] [[Multifocal atrial tachycardia (MAT)|multifocal atrial tachycardia]], [[AV nodal ablation]] has been [[Proof|proven]] beneficial.
*According to [[Study design|studies]], an [[average]] [[reduction]] of 56 [[beats per minute]] in the [[ventricular]] [[rate]] is found with [[Adequate stimulus|adequate]] [[control]] of [[ventricular]] [[Response element|response]] in 84% of the [[patients]].
*However, [[AV nodal ablation]] [[causes]] a [[complete heart block]] and requires the placement of a [[permanent pacemaker]].
|}


==Prevention==
==Prevention==
===Primary Prevention===
===Primary Prevention===
*Magnesium-sparing diuretics should be used in the treatment of patients with chronic obstructive pulmonary disease and congestive heart failure, which are both conditions associated with magnesium deficiency and MAT.<ref name="pmid3275209">{{cite journal| author=Cohen L, Kitzes R, Shnaider H| title=Multifocal atrial tachycardia responsive to parenteral magnesium. | journal=Magnes Res | year= 1988 | volume= 1 | issue= 3-4 | pages= 239-42 | pmid=3275209 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3275209  }} </ref>
*[[Patients]] with [[chronic obstructive pulmonary disease]] and [[congestive heart failure]], both [[conditions]] [[Association (statistics)|associated]] with [[Magnesium deficiency (medicine)|magnesium deficiency]] and [[Multifocal atrial tachycardia (MAT)|MAT]], should be [[Treatments|treated]] with [[magnesium]]-sparing [[diuretics]] in order to [[Prevention (medical)|prevent]] [[Magnesium deficiency (medicine)|magnesium deficiency]] [[Lead|leading]] to [[Multifocal atrial tachycardia (MAT)|MAT]].<ref name="pmid3275209">{{cite journal| author=Cohen L, Kitzes R, Shnaider H| title=Multifocal atrial tachycardia responsive to parenteral magnesium. | journal=Magnes Res | year= 1988 | volume= 1 | issue= 3-4 | pages= 239-42 | pmid=3275209 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3275209  }} </ref>


==Differentiating Multifocal Atrial Tachycardia From Other Disease==
==Differentiating Multifocal Atrial Tachycardia from other Diseases==
[[Multifocal atrial tachycardia (MAT)|Multifocal atrial tachycardia]] must be [[Differentiate|differentiated]] from the following:
*[[Atrial fibrillation]] (has [[Discrete distribution|discrete]] [[P wave]] [[Morphology (biology)|morphologies]])
*[[Atrial flutter]] with [[variable]] [[Atrioventricular node|AV node]] [[Conduction System|conduction]] (has [[Regularization (machine learning)|regular]] [[PP interval|PP intervals]] and [[flutter]] [[waves]])
*[[Atrioventricular nodal reentry tachycardia]] ([[AV nodal reentrant tachycardia|AVNRT]])
*[[Paroxysmal supraventricular tachycardia]]
*[[Premature atrial contractions]] ([[PAC]])
*[[Wolff-Parkinson-White syndrome]] ([[Wolff-Parkinson-White syndrome|WPW]])
*[[Ventricular fibrillation]] ([[Ventricular fibrillation|VF]])
*[[Ventricular tachycardia]] ([[Ventricular tachycardia|VT]]) with [[Frequentist|frequent]] [[premature atrial contractions]] (has [[Regularization (machine learning)|regular]] [[PP interval|PP intervals]])
*[[Wandering atrial pacemaker]] (has [[heart rate]] less than 100 [[beats per minute]])
*


{| class="wikitable"
{| class="wikitable"
Line 319: Line 439:
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Co-existing Conditions
! align="center" style="background:#4479BA; color: #FFFFFF;" + |Co-existing Conditions
|-
|-
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''Atrial Fibrillation (AFib)<ref name="pmid24837984">{{cite journal |vauthors=Lankveld TA, Zeemering S, Crijns HJ, Schotten U |title=The ECG as a tool to determine atrial fibrillation complexity |journal=Heart |volume=100 |issue=14 |pages=1077–84 |date=July 2014 |pmid=24837984 |doi=10.1136/heartjnl-2013-305149 |url=}}</ref><ref name="pmid22518390">{{cite journal |vauthors=Harris K, Edwards D, Mant J |title=How can we best detect atrial fibrillation? |journal=J R Coll Physicians Edinb |volume=42 Suppl 18 |issue= |pages=5–22 |date=2012 |pmid=22518390 |doi=10.4997/JRCPE.2012.S02 |url=}}</ref>'''
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Atrial fibrillation|Atrial fibrillation (AFib)]]<ref name="pmid24837984">{{cite journal |vauthors=Lankveld TA, Zeemering S, Crijns HJ, Schotten U |title=The ECG as a tool to determine atrial fibrillation complexity |journal=Heart |volume=100 |issue=14 |pages=1077–84 |date=July 2014 |pmid=24837984 |doi=10.1136/heartjnl-2013-305149 |url=}}</ref><ref name="pmid22518390">{{cite journal |vauthors=Harris K, Edwards D, Mant J |title=How can we best detect atrial fibrillation? |journal=J R Coll Physicians Edinb |volume=42 Suppl 18 |issue= |pages=5–22 |date=2012 |pmid=22518390 |doi=10.4997/JRCPE.2012.S02 |url=}}</ref>'''
|
|
* Irregularly irregular
*[[Irregularly irregular pulse|Irregularly irregular]]
|
|
* On a 10-second 12-lead [[The electrocardiogram|EKG]] strip, multiply number of [[QRS complexes]] by 6
* On a 10-[[second]] [[12-lead ECG|12-lead EKG]] [[Stripping|strip]], multiply [[number]] of [[QRS complexes]] by 6
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* Absent
* Absent
*Fibrillatory waves
*[[Fibrillation|Fibrillatory]] [[waves]]
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* Absent
* Absent
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* Less than 0.12 seconds, consistent, and normal in morphology in the absence of aberrant conduction
* Less than 0.12 [[Second|seconds]], [[Consistency (statistics)|consistent]], and [[normal]] in [[Morphology (biology)|morphology]] in the absence of aberrant [[Conduction System|conduction]]
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* Does not break with [[adenosine]] or [[vagal maneuvers]]
* Does not break with [[adenosine]] or [[vagal maneuvers]]
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* 2.7–6.1 million people in the United States have AFib
* 2.7–6.1 million [[People's Solidarity|people]] in the [[United States]] have [[Atrial fibrillation|AFib]]
* 2% of people younger than age 65 have AFib, while about 9% of people aged 65 years or older have AFib
* 2% of [[People's Solidarity|people]] [[Young adult|younger]] than [[age]] 65 have [[Atrial fibrillation|AFib]], while about 9% of [[People's Solidarity|people]] [[Age|aged]] 65 [[Year|years]] or [[Old age|older]] have [[Atrial fibrillation|AFib]]
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* Elderly
*[[Elderly]]
* Following [[Coronary artery bypass surgery|bypass surgery]]
* Following [[Coronary artery bypass surgery|bypass surgery]]
*[[Mitral valve disease]]
*[[Mitral valve disease]]
Line 345: Line 465:
*[[Ischemic heart disease]]
*[[Ischemic heart disease]]
*[[Chronic kidney disease]]
*[[Chronic kidney disease]]
* Heavy [[alcohol]] use
* Heavy [[Alcohol abuse|alcohol use]]
* Left chamber enlargement
* Left chamber enlargement
|-
|-
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Atrial Flutter]]'''<ref name="pmid28835836">{{cite journal |vauthors=Cosío FG |title=Atrial Flutter, Typical and Atypical: A Review |journal=Arrhythm Electrophysiol Rev |volume=6 |issue=2 |pages=55–62 |date=June 2017 |pmid=28835836 |pmc=5522718 |doi=10.15420/aer.2017.5.2 |url=}}</ref>
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Atrial Flutter|Atrial flutter]]'''<ref name="pmid28835836">{{cite journal |vauthors=Cosío FG |title=Atrial Flutter, Typical and Atypical: A Review |journal=Arrhythm Electrophysiol Rev |volume=6 |issue=2 |pages=55–62 |date=June 2017 |pmid=28835836 |pmc=5522718 |doi=10.15420/aer.2017.5.2 |url=}}</ref>
|
|
* Regular or Irregular
* Regular or [[Irregular heart rhythms|Irregular]]
|
|
* 75 (4:1 block), 100 (3:1 block) and 150 (2:1 block) beats per minute (bpm), but 150 is more common
* 75 (4:1 [[Blocking (statistics)|block]]), 100 (3:1 [[Blocking (statistics)|block]]) and 150 (2:1 [[Blocking (statistics)|block]]) [[beats per minute]] (bpm), but 150 is more common
|
|
* Sawtooth pattern of P waves at 250 to 350 bpm
* Sawtooth [[pattern]] of [[P waves]] at 250 to 350 [[Beats per minute|bpm]]
*Biphasic deflection in V1
*[[Biphasic]] deflection in [[V1-morph|V1]]
|
|
* Varies depending upon the magnitude of the block, but is short
*[[Variance|Varies]] [[Dependent variable|depending]] upon the [[Magnitude (mathematics)|magnitude]] of the [[Blocking (statistics)|block]], but is [[Shortening|short]]
|
|
* Less than 0.12 seconds, consistent, and normal in morphology
* Less than 0.12 [[Second|seconds]], [[Consistency (statistics)|consistent]], and [[normal]] in [[Morphology (biology)|morphology]]
|
|
* Conduction may vary in response to drugs and maneuvers dropping the rate from 150 to 100 or to 75 bpm
*[[Conduction System|Conduction]] may [[Variable|vary]] in [[Response variable|response]] to [[drugs]] and maneuvers [[Drop (liquid)|dropping]] the [[rate]] from 150 to 100 or to 75 [[Beats per minute|bpm]]
|
|
*[[Incidence]]: 88 per 100,000 individuals
*[[Incidence]]: 88 per 100,000 [[Individual growth|individuals]]
|
|
*[[Elderly]]
*[[Elderly]]
Line 372: Line 492:
* Regular
* Regular
|
|
* 140-280 bpm
* 140-280 [[Beats per minute|bpm]]
|
|
*Slow-Fast AVNRT:
*[[Slow]]-[[Fast and wide|Fast]] [[AVNRT]]:
**Pseudo-S wave in leads II, III, and AVF
**Pseudo-[[S wave]] in [[Lead|leads]] II, III, and AVF
**Pseudo-R' in lead V1.
**Pseudo-R' in [[lead]] [[V1-morph|V1]].
*Fast-Slow AVNRT
*[[Fast and wide|Fast]]-[[Slow]] [[AVNRT]]
**[[P waves]] between the [[QRS complex|QRS]] and [[T waves]] (QRS-P-T complexes)
**[[P waves]] between the [[QRS complex|QRS]] and [[T waves]] ([[QRS complex|QRS]]-[[P wave|P]]-[[T wave|T complexes]])
*Slow-Slow AVNRT
*[[Slow]]-[[Slow]] [[AVNRT]]
**Late [[P waves]] after a [[QRS complex|QRS]]
**Late [[P waves]] after a [[QRS complex|QRS]]
**Often appears as [[atrial tachycardia]].
**Often [[Appearance|appears]] as [[atrial tachycardia]].
*Inverted, superimposed on or buried within the [[QRS complex]] (pseudo R prime in V1/pseudo S wave in inferior leads)
*[[Invert|Inverted]], [[Superimposition|superimposed]] on or buried within the [[QRS complex]] ([[Pseudo-Cushing syndrome|pseudo]] [[R wave|R]] [[Prime EKG|prime]] in [[V1-morph|V1]]/pseudo [[S wave]] in inferior [[Lead|leads]])
|
|
* Absent ([[P wave]] can appear after the QRS complex and before the T wave, and in atypical AVNRT, the [[P wave]] can appear just before the [[QRS complex]])
* Absent ([[P wave]] can [[Appearance|appear]] after the [[QRS complex]] and before the [[T wave]], and in [[Atypical AV nodal reentrant tachycardia|atypical AVNRT]], the [[P wave]] can [[Appearance|appear]] just before the [[QRS complex]])
|
|
* Less than 0.12 seconds, consistent, and normal in morphology in the absence of aberrant conduction
* Less than 0.12 [[Second|seconds]], [[Consistency (statistics)|consistent]], and [[normal]] in [[Morphology (biology)|morphology]] in the absence of aberrant [[Conduction System|conduction]]
*[[QRS complex alternans|QRS alternans]] may be present
*[[QRS complex alternans|QRS alternans]] may be [[Presenting symptoms|present]]
|
|
* May break with [[adenosine]] or [[vagal maneuvers]]
* May break with [[adenosine]] or [[vagal maneuvers]]
Line 396: Line 516:
*[[Atrial tachyarrhythmias]]
*[[Atrial tachyarrhythmias]]
|-
|-
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Multifocal atrial tachycardia|Multifocal Atrial Tachycardia]]<ref name="pmid2570520">{{cite journal |vauthors=Scher DL, Arsura EL |title=Multifocal atrial tachycardia: mechanisms, clinical correlates, and treatment |journal=Am. Heart J. |volume=118 |issue=3 |pages=574–80 |date=September 1989 |pmid=2570520 |doi=10.1016/0002-8703(89)90275-5 |url=}}</ref><ref name="pmid11884328">{{cite journal |vauthors=Goodacre S, Irons R |title=ABC of clinical electrocardiography: Atrial arrhythmias |journal=BMJ |volume=324 |issue=7337 |pages=594–7 |date=March 2002 |pmid=11884328 |pmc=1122515 |doi=10.1136/bmj.324.7337.594 |url=}}</ref>'''
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Multifocal atrial tachycardia (MAT)|Multifocal atrial tachycardia]]<ref name="pmid2570520">{{cite journal |vauthors=Scher DL, Arsura EL |title=Multifocal atrial tachycardia: mechanisms, clinical correlates, and treatment |journal=Am. Heart J. |volume=118 |issue=3 |pages=574–80 |date=September 1989 |pmid=2570520 |doi=10.1016/0002-8703(89)90275-5 |url=}}</ref><ref name="pmid11884328">{{cite journal |vauthors=Goodacre S, Irons R |title=ABC of clinical electrocardiography: Atrial arrhythmias |journal=BMJ |volume=324 |issue=7337 |pages=594–7 |date=March 2002 |pmid=11884328 |pmc=1122515 |doi=10.1136/bmj.324.7337.594 |url=}}</ref>'''
|
|
* Irregular
*[[Irregular heart rhythms|Irregular]]
|
|
*[[Atrial]] rate is > 100 beats per minute
*[[Atrial]] rate is > 100 [[beats per minute]]
|
|
* Varying morphology from at least three different foci
* Varying [[morphology]] from at least three [[Differentiate|different]] [[Focusing|foci]]
* Absence of one dominant atrial pacemaker, can be mistaken for [[atrial fibrillation]] if the [[P waves]] are of low amplitude
* Absence of one [[dominant]] [[atrial]] [[pacemaker]], can be mistaken for [[atrial fibrillation]] if the [[P waves]] are of low [[amplitude]]
|
|
* Variable [[PR interval|PR intervals]], RR intervals, and PP intervals
*[[Variable]] [[PR interval|PR intervals]], [[RR interval|RR intervals]], and [[PP interval|PP intervals]]
|
|
* Less than 0.12 seconds, consistent, and normal in morphology
* Less than 0.12 [[Second|seconds]], [[Consistency (statistics)|consistent]], and [[normal]] in [[Morphology (biology)|morphology]]
|
|
* Does not terminate with [[adenosine]] or [[vagal maneuvers]]
* Does not [[Termination signal|terminate]] with [[adenosine]] or [[vagal maneuvers]]
|
|
* 0.05% to 0.32% of [[electrocardiograms]] in general hospital admissions
* 0.05% to 0.32% of [[electrocardiograms]] in [[Generalization|general]] [[hospital]] [[Admission note|admissions]]
|
|
*[[Elderly]]
*[[Elderly]]
*[[Chronic obstructive pulmonary disease]] ([[Chronic obstructive pulmonary disease|COPD]])
*[[Chronic obstructive pulmonary disease]] ([[Chronic obstructive pulmonary disease|COPD]])
|-
|-
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''Paroxysmal Supraventricular Tachycardia'''
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Paroxysmal supraventricular tachycardia]]'''
|
|
* Regular
* Regular
|
|
* 150 and 240 bpm
* 150 and 240 [[Beats per minute|bpm]]
|
|
* Absent
* Absent
Line 427: Line 547:
* Absent
* Absent
|
|
* Narrow complexes (< 0.12 s)
* Narrow [[Complex (chemistry)|complexes]] (< 0.12 s)
|
|
* Breaks with [[vagal maneuvers]], [[adenosine]], [[diving reflex]], [[oculocardiac reflex]]
* Breaks with [[vagal maneuvers]], [[adenosine]], [[diving reflex]], [[oculocardiac reflex]]
Line 439: Line 559:
*[[Wolff-Parkinson-White syndrome]]
*[[Wolff-Parkinson-White syndrome]]
|-
|-
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Premature atrial contraction|Premature Atrial Contractrions]] ([[Premature atrial contraction|PAC]])'''<ref name="pmid26316525">{{cite journal |vauthors=Lin CY, Lin YJ, Chen YY, Chang SL, Lo LW, Chao TF, Chung FP, Hu YF, Chong E, Cheng HM, Tuan TC, Liao JN, Chiou CW, Huang JL, Chen SA |title=Prognostic Significance of Premature Atrial Complexes Burden in Prediction of Long-Term Outcome |journal=J Am Heart Assoc |volume=4 |issue=9 |pages=e002192 |date=August 2015 |pmid=26316525 |pmc=4599506 |doi=10.1161/JAHA.115.002192 |url=}}</ref><ref name="pmid18063110">{{cite journal |vauthors=Strasburger JF, Cheulkar B, Wichman HJ |title=Perinatal arrhythmias: diagnosis and management |journal=Clin Perinatol |volume=34 |issue=4 |pages=627–52, vii–viii |date=December 2007 |pmid=18063110 |pmc=3310372 |doi=10.1016/j.clp.2007.10.002 |url=}}</ref>
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Premature atrial contraction|Premature atrial contractrions]] ([[Premature atrial contraction|PAC]])'''<ref name="pmid26316525">{{cite journal |vauthors=Lin CY, Lin YJ, Chen YY, Chang SL, Lo LW, Chao TF, Chung FP, Hu YF, Chong E, Cheng HM, Tuan TC, Liao JN, Chiou CW, Huang JL, Chen SA |title=Prognostic Significance of Premature Atrial Complexes Burden in Prediction of Long-Term Outcome |journal=J Am Heart Assoc |volume=4 |issue=9 |pages=e002192 |date=August 2015 |pmid=26316525 |pmc=4599506 |doi=10.1161/JAHA.115.002192 |url=}}</ref><ref name="pmid18063110">{{cite journal |vauthors=Strasburger JF, Cheulkar B, Wichman HJ |title=Perinatal arrhythmias: diagnosis and management |journal=Clin Perinatol |volume=34 |issue=4 |pages=627–52, vii–viii |date=December 2007 |pmid=18063110 |pmc=3310372 |doi=10.1016/j.clp.2007.10.002 |url=}}</ref>
|
|
* Regular except when disturbed by premature beat(s)
* Regular except when disturbed by [[premature]] [[Beats per minute|beat(s)]]
|
|
* 80-120 bpm
* 80-120 [[Beats per minute|bpm]]
|
|
* Upright
* Upright
|
|
* > 0.12 second
* > 0.12 [[Second|seconds]]
* May be shorter than that in normal sinus rhythm (NSR) if the origin of PAC is located closer to the AV node
* May be [[Shortening|shorter]] than that in [[normal sinus rhythm]] ([[Normal sinus rhythm|NSR]]) if the [[origin]] of [[PAC]] is [[Location parameter|located]] closer to the [[AV node]]
*Ashman’s Phenomenon:
*[[Ashman phenomenon|Ashman’s Phenomenon]]:
**[[Premature atrial contraction|PAC]] displaying a [[right bundle branch block]] pattern
**[[Premature atrial contraction|PAC]] displaying a [[right bundle branch block]] [[pattern]]
|
|
* Usually narrow (< 0.12 s)
* Usually narrow (< 0.12 s)
Line 470: Line 590:
* Regular
* Regular
|
|
* Atrial rate is nearly 300 bpm and ventricular rate is at 150 bpm
*[[Atrial]] rate is nearly 300 [[Beats per minute|bpm]] and [[ventricular]] rate is at 150 [[Beats per minute|bpm]]
|
|
* With [[orthodromic]] conduction due to a bypass tract, the [[P wave]] generally follows the [[QRS complex]], whereas in [[AVNRT]], the [[P wave]] is generally buried in the [[QRS complex]].
* With [[orthodromic]] [[Conduction System|conduction]] due to a [[bypass tract]], the [[P wave]] [[Generalization|generally]] follows the [[QRS complex]], whereas in [[AVNRT]], the [[P wave]] is [[Generalization|generally]] buried in the [[QRS complex]].
|
|
* Less than 0.12 seconds
* Less than 0.12 [[Second|seconds]]
|
|
* A [[delta wave]] and evidence of [[ventricular]] pre-excitation if there is conduction to the ventricle via ante-grade conduction down an accessory pathway
* A [[delta wave]] and [[evidence]] of [[ventricular]] [[pre-excitation]] if there is [[Conduction System|conduction]] to the [[ventricle]] via ante-grade [[Conduction System|conduction]] down an [[accessory pathway]]
* A [[delta wave]] and pre-excitation may not be present because bypass tracts do not conduct ante-grade.
* A [[delta wave]] and [[pre-excitation]] may not be present because [[Bypass tract|bypass tracts]] do not [[conduct]] ante-grade.
|
|
* May break in response to [[procainamide]], [[adenosine]], [[vagal maneuvers]]
* May break in [[Response variable|response]] to [[procainamide]], [[adenosine]], [[vagal maneuvers]]
|
|
* Worldwide [[prevalence]] of [[Wolff-Parkinson-White syndrome|WPW syndrome]] is 100 - 300 per 100,000
* Worldwide [[prevalence]] of [[Wolff-Parkinson-White syndrome|WPW syndrome]] is 100 - 300 per 100,000
|
|
*[[Ebstein's anomaly]]
*[[Ebstein's anomaly]]
*[[Mitral valve prolapse]]: This cardiac disorder, if present, is associated with left-sided accessory pathways.
*[[Mitral valve prolapse]]: This [[cardiac]] [[Disorder (medicine)|disorder]], if [[Presenting symptom|present]], is [[Association (statistics)|associated]] with left-sided [[accessory pathways]].
*[[Hypertrophic cardiomyopathy]]: This disorder is associated with familial/inherited form of [[Wolff-Parkinson-White syndrome|WPW syndrome]].
*[[Hypertrophic cardiomyopathy]]: This [[Disorder (medicine)|disorder]] is [[Association (statistics)|associated]] with [[familial]]/[[inherited]] form of [[Wolff-Parkinson-White syndrome|WPW syndrome]].
*[[Hypokalemic periodic paralysis]]
*[[Hypokalemic periodic paralysis]]
*[[Pompe disease]]
*[[Pompe disease]]
*[[Tuberous sclerosis]]
*[[Tuberous sclerosis]]
|-
|-
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Ventricular fibrillation|Ventricular Fibrillation]] (VF)'''<ref name="pmid27899944">{{cite journal |vauthors=Glinge C, Sattler S, Jabbari R, Tfelt-Hansen J |title=Epidemiology and genetics of ventricular fibrillation during acute myocardial infarction |journal=J Geriatr Cardiol |volume=13 |issue=9 |pages=789–797 |date=September 2016 |pmid=27899944 |pmc=5122505 |doi=10.11909/j.issn.1671-5411.2016.09.006 |url=}}</ref><ref name="pmid11334828">{{cite journal |vauthors=Samie FH, Jalife J |title=Mechanisms underlying ventricular tachycardia and its transition to ventricular fibrillation in the structurally normal heart |journal=Cardiovasc. Res. |volume=50 |issue=2 |pages=242–50 |date=May 2001 |pmid=11334828 |doi=10.1016/s0008-6363(00)00289-3 |url=}}</ref><ref name="pmid20142817">{{cite journal |vauthors=Adabag AS, Luepker RV, Roger VL, Gersh BJ |title=Sudden cardiac death: epidemiology and risk factors |journal=Nat Rev Cardiol |volume=7 |issue=4 |pages=216–25 |date=April 2010 |pmid=20142817 |pmc=5014372 |doi=10.1038/nrcardio.2010.3 |url=}}</ref>
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Ventricular fibrillation|Ventricular fibrillation (VF)]]'''<ref name="pmid27899944">{{cite journal |vauthors=Glinge C, Sattler S, Jabbari R, Tfelt-Hansen J |title=Epidemiology and genetics of ventricular fibrillation during acute myocardial infarction |journal=J Geriatr Cardiol |volume=13 |issue=9 |pages=789–797 |date=September 2016 |pmid=27899944 |pmc=5122505 |doi=10.11909/j.issn.1671-5411.2016.09.006 |url=}}</ref><ref name="pmid11334828">{{cite journal |vauthors=Samie FH, Jalife J |title=Mechanisms underlying ventricular tachycardia and its transition to ventricular fibrillation in the structurally normal heart |journal=Cardiovasc. Res. |volume=50 |issue=2 |pages=242–50 |date=May 2001 |pmid=11334828 |doi=10.1016/s0008-6363(00)00289-3 |url=}}</ref><ref name="pmid20142817">{{cite journal |vauthors=Adabag AS, Luepker RV, Roger VL, Gersh BJ |title=Sudden cardiac death: epidemiology and risk factors |journal=Nat Rev Cardiol |volume=7 |issue=4 |pages=216–25 |date=April 2010 |pmid=20142817 |pmc=5014372 |doi=10.1038/nrcardio.2010.3 |url=}}</ref>
|
|
* Irregular
*[[Irregular heart rhythms|Irregular]]
|
|
* 150 to 500 bpm
* 150 to 500 [[Beats per minute|bpm]]
|
|
* Absent
* Absent
Line 500: Line 620:
* Absent
* Absent
|
|
* Absent (R on T phenomenon in the setting of ischemia)
* Absent ([[R wave|R]] on [[T wave|T]] [[Phenomenology|phenomenon]] in the [[Set|setting]] of [[ischemia]])
|
|
* Does not break in response to [[procainamide]], [[adenosine]], [[vagal maneuvers]]
* Does not break in [[Response variable|response]] to [[procainamide]], [[adenosine]], [[vagal maneuvers]]
|
|
* 3-12% cases of [[acute myocardial infarction]] (AMI)
* 3-12% [[Case-based reasoning|cases]] of [[acute myocardial infarction]] ([[Acute myocardial infarction|AMI]])
* Out of 356,500 out of hospital cardiac arrests, 23% have VF as initial rhythm
* Out of 356,500 out of [[hospital]] [[Cardiac arrest|cardiac arrests]], 23% have [[Ventricular fibrillation|VF]] as initial [[rhythm]]
|
|
*[[Myocardial ischemia]] / [[Myocardial infarction|infarction]]
*[[Myocardial ischemia]] / [[Myocardial infarction|infarction]]
*[[Cardiomyopathy]]
*[[Cardiomyopathy]]
* Channelopathies e.g. Long QT (acquired / congenital)
*[[Channelopathies]] e.g. [[Long QT]] ([[acquired]] / [[congenital]])
*Electrolyte abnormalities ([[hypokalemia]]/[[hyperkalemia]], [[hypomagnesemia]])
*[[Electrolyte abnormalities]] ([[hypokalemia]]/[[hyperkalemia]], [[hypomagnesemia]])
*[[Aortic stenosis]]
*[[Aortic stenosis]]
*[[Aortic dissection]]
*[[Aortic dissection]]
*[[Myocarditis]]
*[[Myocarditis]]
*[[Cardiac tamponade]]
*[[Cardiac tamponade]]
* Blunt trauma (Commotio Cordis)
*[[Blunt trauma]] ([[Commotio cordis|Commotio Cordis]])
*[[Sepsis]]
*[[Sepsis]]
*[[Hypothermia]]
*[[Hypothermia]]
Line 522: Line 642:
*[[Stroke]]
*[[Stroke]]
|-
|-
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Ventricular tachycardia|Ventricular Tachycardia]]'''<ref name="pmid19252119">{{cite journal |vauthors=Koplan BA, Stevenson WG |title=Ventricular tachycardia and sudden cardiac death |journal=Mayo Clin. Proc. |volume=84 |issue=3 |pages=289–97 |date=March 2009 |pmid=19252119 |pmc=2664600 |doi=10.1016/S0025-6196(11)61149-X |url=}}</ref><ref name="pmid21505622">{{cite journal |vauthors=Levis JT |title=ECG Diagnosis: Monomorphic Ventricular Tachycardia |journal=Perm J |volume=15 |issue=1 |pages=65 |date=2011 |pmid=21505622 |pmc=3048638 |doi=10.7812/tpp/10-130 |url=}}</ref>
|style="padding: 5px 5px; background: #DCDCDC; font-weight: bold" |'''[[Ventricular tachycardia]]'''<ref name="pmid19252119">{{cite journal |vauthors=Koplan BA, Stevenson WG |title=Ventricular tachycardia and sudden cardiac death |journal=Mayo Clin. Proc. |volume=84 |issue=3 |pages=289–97 |date=March 2009 |pmid=19252119 |pmc=2664600 |doi=10.1016/S0025-6196(11)61149-X |url=}}</ref><ref name="pmid21505622">{{cite journal |vauthors=Levis JT |title=ECG Diagnosis: Monomorphic Ventricular Tachycardia |journal=Perm J |volume=15 |issue=1 |pages=65 |date=2011 |pmid=21505622 |pmc=3048638 |doi=10.7812/tpp/10-130 |url=}}</ref>
|
|
* Regular
* Regular
|
|
* > 100 bpm (150-200 bpm common)
* > 100 [[Beats per minute|bpm]] (150-200 [[Beats per minute|bpm]] common)
|
|
* Absent
* Absent
Line 532: Line 652:


*Absent
*Absent
*Initial [[R wave]] in V1, initial r > 40 ms in V1/V2, notched S in V1, initial R in aVR, lead II R wave peak time ≥50 ms, no RS in V1-V6, and atrioventricular dissociation
*Initial [[R wave]] in [[V1-morph|V1]], initial [[R wave|r]] > 40 [[Millisecond|ms]] in V1/V2, [[Notch|notched]] [[S wave|S]] in [[V1-morph|V1]], initial [[R wave|R]] in [[aVR]], [[lead]] II [[R wave]] peak [[Time constant|time]] ≥50 [[Millisecond|ms]], no RS in [[V1-morph|V1]]-V6, and [[atrioventricular dissociation]]
|
|
* Wide complex, [[QRS complex|QRS]] duration > 120 milliseconds
*[[Wide complex tachycardia|Wide complex]], [[QRS complex|QRS]] duration > 120 [[Millisecond|milliseconds]]
|
|
* Does not break in response to [[procainamide]], [[adenosine]], [[vagal maneuvers]]
* Does not break in [[Response variable|response]] to [[procainamide]], [[adenosine]], [[vagal maneuvers]]
|
|
* 5-10% of patients presenting with AMI
* 5-10% of [[patients]] [[Presenting symptom|presenting]] with [[Acute myocardial infarction|AMI]]
|
|
*[[Coronary artery disease]]
*[[Coronary artery disease]]
Line 544: Line 664:
*[[Cardiomyopathy]]
*[[Cardiomyopathy]]
*[[Electrolyte imbalance|Electrolyte imbalances]] (e.g., [[hypokalemia]], [[hypomagnesemia]])
*[[Electrolyte imbalance|Electrolyte imbalances]] (e.g., [[hypokalemia]], [[hypomagnesemia]])
* Inherited [[channelopathies]] (e.g., [[long-QT syndrome]])
*[[Inherited]] [[channelopathies]] (e.g., [[long-QT syndrome]])
*[[Catecholaminergic polymorphic ventricular tachycardia]]
*[[Catecholaminergic polymorphic ventricular tachycardia]]
*[[Arrhythmogenic right ventricular dysplasia]]
*[[Arrhythmogenic right ventricular dysplasia]]
*[[Myocardial infarction]]
*[[Myocardial infarction]]
*[[Torsades de pointes]] is a form of polymorphic VT that is often associated with a prolonged [[QT interval]]
*[[Torsades de pointes]] is a form of [[polymorphic VT]] that is often [[Association (statistics)|associated]] with a [[Prolonged QT Interval|prolonged QT interval]]
|}
|}


Line 554: Line 674:
{{Reflist|2}}
{{Reflist|2}}


==Additional resources==
[[Category:Disease]]
* [http://en.ecgpedia.org ECGpedia: Course for interpretation of ECG]
 
 
[[Category:Crowdiagnosis]]
[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Arrhythmias]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date cardiology]]
[[Category:Medicine]]
[[Category:Arrhythmia]]
[[Category:Electrophysiology]]
[[Category:Disease]]


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Latest revision as of 20:58, 19 August 2020

Multifocal atrial tachycardia Microchapters

Overview

Historical Perspective

Pathophysiology

Causes

Epidemiology and Demographics

Natural History, Complications and Prognosis

Diagnosis

Treatment

Prevention

Differentiating Multifocal Atrial Tachycardia from other Diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor-In-Chief: Sara Mohsin, M.D.[2], Cafer Zorkun, M.D., Ph.D. [3], Syed Hassan A. Kazmi BSc, MD [4]

Synonyms and keywords: MAT, Chaotic atrial tachycardia, Supraventricular tachycardia

Overview

Multifocal atrial tachycardia (MAT) is a cardiac arrhythmia which is specifically a type of supraventricular tachycardia with an irregular, rapid atrial rhythm arising from multiple ectopic foci within the atria with a heart rate exceeding 100 beats per minute. It is characterized by an organized atrial activity yielding three or more different non-sinus P wave morphologies in the same lead with variable or irregular PP, PR and RR intervals. There's an isoelectric baseline between P waves with the most P waves being conducted to the ventricles and some R waves being aberrantly conducted. This variability pattern makes MAT look irregular on the surface ECG, thus oftenly leading to misinterpretion as atrial fibrillation. It is typically seen in elderly patients with a variety of underlying comorbidities, the most common being chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) and eventually it develops into atrial fibrillation. A rhythm with similar ECG characteristics but at a slow rate is referred to as multifocal atrial rhythm (MAR). The pathogenesis of MAT is not well understood and the patients are generally asymptomatic with mostly being hemodynamically stable. Typically, no treatment is required beyond treatment of underlying conditions in the majority of the MAT patients. However, it is very important to evaluate such patients as this arrhythmia is a poor prognostic sign in the setting of an acute illness.

Historical Perspective

Pathophysiology

Proposed theories suggesting the underlying mechanism of MAT
Theory Description
Theory of re-entry
Theory of abnormal automaticity
Theory of triggered activity
Multifocal Atrial Tachycardia.
Multifocal atrial tachycardia (MAT) [https://en.wikipedia.org/wiki/Multifocal_atrial_tachycardia#/media/File:Multifocal_atrial_tachycardia_-_MAT.png

Causes

Following is a list of potential causes of multifocal atrial tachycardia:

Life Threatening Causes

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

Common Causes


Causes by Organ System

Cardiovascular Congestive heart failure, myocardial infarction,
Chemical/Poisoning No underlying causes
Dental No underlying causes
Dermatologic No underlying causes
Drug Side Effect Aminophylline,, theophylline
Ear Nose Throat No underlying causes
Endocrine Diabetes mellitus
Environmental No underlying causes
Gastroenterologic No underlying causes
Genetic No underlying causes
Hematologic No underlying causes
Iatrogenic Postoperative complication
Infectious Disease Pneumonia, sepsis
Musculoskeletal/Orthopedic No underlying causes
Neurologic No underlying causes
Nutritional/Metabolic No underlying causes
Obstetric/Gynecologic No underlying causes
Oncologic Lung cancer
Ophthalmologic No underlying causes
Overdose/Toxicity Aminophylline
Psychiatric No underlying causes
Pulmonary Chronic obstructive pulmonary disease, hypoxia, lung cancer, pneumonia, pulmonary embolism
Renal/Electrolyte Chronic renal failure, hypokalemia, hypomagnesemia
Rheumatology/Immunology/Allergy No underlying causes
Sexual No underlying causes
Trauma No underlying causes
Urologic No underlying causes
Miscellaneous No underlying causes

Causes in Alphabetical Order

Epidemiology and Demographics

Natural history, Complications and Prognosis

Diagnosis

The diagnosis of MAT is usually not clinical rather the following electrocardiographic diagnostic criteria is used:

Electrocardiography

ECG of MAT has following characteristics:

Other diagnostic workup

Challenges in MAT pediatric patients

Challenges faced by pediatric practitioners while treating children with multifocal atrial tachycardia
Challenges Details
How to detect MAT early
How to control MAT
How deep to investigate etiologies of MAT[30]
How to predict another arrhythmia and outcome[2][26][31][32]

History and Symptoms

Physical Examination

Treatment

Treatment options for multifocal atrial tachycardia
Treatment option Description
Treat underlying medical condition
Magnesium repletion[33][34][35][36][37][38][39][26][40][36]


Potassium repletion[34]
Non-dihydropyridine calcium channel blockers
Beta blockers
Antiarrhythmic drugs[41][31][42]
Radiofrequency AV nodal ablation

Prevention

Primary Prevention

Differentiating Multifocal Atrial Tachycardia from other Diseases

Multifocal atrial tachycardia must be differentiated from the following:

Arrhythmia Rhythm Rate P wave PR Interval QRS Complex Response to Maneuvers Epidemiology Co-existing Conditions
Atrial fibrillation (AFib)[43][44]
  • Absent
Atrial flutter[45]
Atrioventricular nodal reentry tachycardia (AVNRT)[46][47][48][49]
  • Regular
Multifocal atrial tachycardia[50][51]
Paroxysmal supraventricular tachycardia
  • Regular
  • 150 and 240 bpm
  • Absent
  • Hidden in QRS
  • Absent
Premature atrial contractrions (PAC)[52][53]
  • Upright
  • Usually narrow (< 0.12 s)
Wolff-Parkinson-White Syndrome[54][55]
  • Regular
Ventricular fibrillation (VF)[56][57][58]
  • Absent
  • Absent
Ventricular tachycardia[59][60]
  • Regular
  • > 100 bpm (150-200 bpm common)
  • Absent

References

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