Narrow complex tachycardia resident survival guide: Difference between revisions
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== Management== | == Management== | ||
===Differential Diagnosis for Narrow QRS Tachycardia<ref name="circ.ahajournals.org">{{Cite web | last = | first = | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher = | date = | accessdate = 15 August 2013 }}</ref>=== | |||
{{familytree/start |summary=PE diagnosis Algorithm.}} | {{familytree/start |summary=PE diagnosis Algorithm.}} | ||
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''Algorithm based on the 2003 ACC/AHA/ESC guidelines for the management of supraventricular arrhythmias.''<ref name="circ.ahajournals.org">{{Cite web | last = | first = | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher = | date = | accessdate = 15 August 2013 }}</ref> | ''Algorithm based on the 2003 ACC/AHA/ESC guidelines for the management of supraventricular arrhythmias.''<ref name="circ.ahajournals.org">{{Cite web | last = | first = | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher = | date = | accessdate = 15 August 2013 }}</ref> | ||
===Differential Diagnosis of Narrow Complex Tachycardias According to Adenosine Response<ref name="circ.ahajournals.org">{{Cite web | last = | first = | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher = | date = | accessdate = 15 August 2013 }}</ref>=== | |||
''' | {{familytree/start}} | ||
{{familytree | | | | | | | | | A01 | | | | | |A01=Regular narrow [[QRS complex]] tachycardia}} | |||
{{familytree | | | | | | | | | |!| | | | | | | | }} | |||
{{familytree | | | | | | | | | B01 | | | | | |B01=IV adenosine}} | |||
{{familytree | |,|-|-|-|v|-|-|-|^|-|-|-|v|-|-|-|.| | }} | |||
{{familytree | |!| | | |!| | | | | | | |!| | | |!| | | }} | |||
{{familytree | C01 | | C02 | | | | | | C03 | | C04 |C01=No change in rate|C02=Gradual slowing then reacceleration of rate |C03=Sudden termination|C04=Persisting atrial tachycardia with transient high-grade AV block}} | |||
{{familytree | |!| | | |!| | | | | | | |!| | | |!| }} | |||
{{familytree | C01 | | C02 | | | | | | C03 | | C04 | | | | | |C01=Inadequate dose/delivery<br>Condiser VT (fascicular or hight septal origin)|C02=Sinus tachycardia<br>Focal AT<br>Nonparoxysmal junctional tachycardia|C03=[[AVNRT]]<br>[[AVRT]]<br>Sinus node re-entry<br>Focal AT|C04=[[Atrial flutter]]<br>AT }} | |||
{{familytree/end}} | |||
AT indicates atrial tachycardia; AV, atrioventricular; AVNRT, atrioventricular nodal reciprocating tachycardia; AVRT, atrioventricular reciprocating tachycardia; IV, intravenous; QRS, ventricular activation on ECG; VT, ventricular tachycardia.<br> | |||
''Algorithm based on the 2003 ACC/AHA/ESC guidelines for the management of supraventricular arrhythmias.''<ref name="circ.ahajournals.org">{{Cite web | last = | first = | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher = | date = | accessdate = 15 August 2013 }}</ref> | |||
===Acute management of Hemodynamically Stable Narrow QRS Regular Tachycadia<ref name="circ.ahajournals.org">{{Cite web | last = | first = | title = ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias—Executive Summary | url = http://circ.ahajournals.org/content/108/15/1871 | publisher = | date = | accessdate = 15 August 2013 }}</ref>=== | |||
{{familytree/start}} | {{familytree/start}} | ||
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==Do's== | ==Do's== | ||
Revision as of 21:38, 2 March 2014
| File:Critical Pathways.gif |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hilda Mahmoudi M.D., M.P.H.[2]
Definition
Narrow complex tachycardia is defined as a rhythm with heart rate > 100 beats per minute and a QRS complex duration < 120 milliseconds.
Causes
Life Threatening Causes
Life-threatening causes include conditions which result in death or permanent disability within 24 hours if left untreated.
Common Causes
Initial Diagnosis
| Charcterize the symptoms | |||||||||||||||||||||||||||||||||||||||
| Examine the patient | |||||||||||||||||||||||||||||||||||||||
Order tests
❑ 24 hour holter monitor
❑ Loop recorder
❑ Trans-esophageal atrial recordings
| |||||||||||||||||||||||||||||||||||||||
| Undocumented arrhythmia | Documented arrhythmia | ||||||||||||||||||||||||||||||||||||||
❑ History suggests extra premature beats. ❑ Surface ECG is normal. | ❑ History suggests paroxysmal arrhythmia. ❑ 12 lead ECG doesn't suggest any mechanism for arrhythmia. | Stable patient | Unstable patient | ||||||||||||||||||||||||||||||||||||
❑ Refer for an invasive electrophysiological study AND/OR ❑ Catheter ablation ❑ Teach vagal maneuvers to patients. ❑ Consider beta blocking agent. | ❑ Treat according to the type of arrhythmia. | ❑ Obtain a monitor strip form the defibrillator. ❑ Immediate direct current cardioversion. | |||||||||||||||||||||||||||||||||||||
Management
Differential Diagnosis for Narrow QRS Tachycardia[1]
| Narrow QRS tachycardia (QRS duration less than 120 ms) | |||||||||||||||||||||||||||||||||||||||||||
| Regular rhythm | Irregular rhythm | ||||||||||||||||||||||||||||||||||||||||||
| P waves present? | Atrial fibrillation Atrial tachycardia/flutter with variable AV conduction MAT | ||||||||||||||||||||||||||||||||||||||||||
| No | Yes | ||||||||||||||||||||||||||||||||||||||||||
| Atrial rate greater than ventricular rate? | |||||||||||||||||||||||||||||||||||||||||||
| Yes | No | ||||||||||||||||||||||||||||||||||||||||||
| Atrial flutter or atrial tachycardia | Analyze RP interval | ||||||||||||||||||||||||||||||||||||||||||
| Short (RP shorter than PR) | Long (RP longer than PR) | ||||||||||||||||||||||||||||||||||||||||||
| RP shorter than 70 ms | RP longer than 70 ms | Atrial tachycardia PJRT Atypical AVNRT | |||||||||||||||||||||||||||||||||||||||||
| AVNRT | AVRT AVNRT Atrial tachycardia | ||||||||||||||||||||||||||||||||||||||||||
† Echocardiographic examination is required in patients with documented sustained supraventricular tachycardia to rule out structural heart disease.
Patients with focal junctional tachycardia may mimic the pattern of slow-fast AVNRT and may show AV dissociation and/or marked irregularity in the junctional rate.
AV indicates atrioventricular; AVNRT, atrioventricular nodal reciprocating tachycardia; MAT, multifocal atrial tachycardia; ms, miliseconds; PJRT, permanent form of junctional reciprocating tachycardia; QRS, ventricular activation on ECG.
Algorithm based on the 2003 ACC/AHA/ESC guidelines for the management of supraventricular arrhythmias.[1]
Differential Diagnosis of Narrow Complex Tachycardias According to Adenosine Response[1]
| Regular narrow QRS complex tachycardia | |||||||||||||||||||||||||||||||||||||||||||||||
| IV adenosine | |||||||||||||||||||||||||||||||||||||||||||||||
| No change in rate | Gradual slowing then reacceleration of rate | Sudden termination | Persisting atrial tachycardia with transient high-grade AV block | ||||||||||||||||||||||||||||||||||||||||||||
| Inadequate dose/delivery Condiser VT (fascicular or hight septal origin) | Sinus tachycardia Focal AT Nonparoxysmal junctional tachycardia | AVNRT AVRT Sinus node re-entry Focal AT | Atrial flutter AT | ||||||||||||||||||||||||||||||||||||||||||||
AT indicates atrial tachycardia; AV, atrioventricular; AVNRT, atrioventricular nodal reciprocating tachycardia; AVRT, atrioventricular reciprocating tachycardia; IV, intravenous; QRS, ventricular activation on ECG; VT, ventricular tachycardia.
Algorithm based on the 2003 ACC/AHA/ESC guidelines for the management of supraventricular arrhythmias.[1]
Acute management of Hemodynamically Stable Narrow QRS Regular Tachycadia[1]
| Hemodynamically stable regular tachycardia | |||||||||||||||||||||||||||||||||||||||||||
| Narrow QRS | |||||||||||||||||||||||||||||||||||||||||||
| SVT | |||||||||||||||||||||||||||||||||||||||||||
| Vagal maneuvers IV adenosine† IV verapamil/diltiazem IV beta blocker | |||||||||||||||||||||||||||||||||||||||||||
| Termination | |||||||||||||||||||||||||||||||||||||||||||
| Yes | No,persistent tachycardia with AV block | ||||||||||||||||||||||||||||||||||||||||||
| *IV ibutilide plus AV-nodal-blocking agent Overdrive pacing/DC cardioversion, and/or rate control | |||||||||||||||||||||||||||||||||||||||||||
†Adenosine should be used with caution in patients with severe coronary artery disease and may produce
AF, which may result in rapid ventricular rates for patients with pre-excitation. *Ibutilide is especially effective for patients with atrial flutter but should not be used in patients with EF less than 30% due to increased risk of polymorphic VT. AF indicates atrial fibrillation; AV, atrioventricular; BBB, bundle-branch block; DC, direct current; IV, intravenous; LV, left ventricle; QRS, ventricular activation on ECG; SVT, supraventricular tachycardia; VT, ventricular tachycardia.
Algorithm based on the 2003 ACC/AHA/ESC guidelines for the management of supraventricular arrhythmias.[1]
Do's
- Refer narrow complex tachycardic patients with following characteristics to a cardiac arrhythmia specialist:
- Patients with drug resistance
- Patients with intolerance to drugs
- Patients who do not want any drug therapy.
- Patients with severe symptoms such as syncope and dyspnoea during palpitations.
- Refer all the patients with Wolff-Parkinson-White syndrome (WPW syndrome) to a cardiac arrhythmia specialist.
Don'ts
- Do not perform esophageal stimulation if an invasive electrophysiological investigation is planned.