Supraventricular tacchycardias
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SUPRAVENTRICULAR
TACCHYCARDIASDr. Sunain Ashraf
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DEFINITION SVT any tachyarrhythmia that requires
atrial and/or atrioventricular (AV) nodal tissue for its initiation and maintenance and
narrow-complex tachycardia regular, rapid rhythm
exceptions atrial fibrillation (AF) multifocal atrial
tachycardia(MAT)
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CLASSIFICATION Depending on the site of origin of the
dysrhythmia, SVTs may be classified as an atrial or AV tachyarrhythmia.
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SUPRAVENTRICULAR TACHYCARDIA
Atrial tachyarrhythmias• (1) sinus tachycardia• (2) inappropriate sinus tachycardia (IST)• (3) sinus nodal reentrant tachycardia (SNRT)• (4) atrial tachycardia• (5) multifocal atrial tachycardia• (6) atrial flutter• (7) atrial fibrillation..
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AV tachyarrhythmias• (1) AV nodal reentrant tachycardia (AVNRT)• (2) AV reentrant tachycardia (AVRT)• (3)junctional ectopic tachycardia (JET)• (4) nonparoxysmal junctional tachycardia (NPJT).
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AVNRTAVRT
AV Tachyarrhythmias
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AV NODAL REENTRANT TACHYCARDIA
most common cause of paroxysmal supraventricular tachycardia is AVNRT.
AVNRT is diagnosed in 50-60% of present with regular narrow QRS tachyarrhythmia.The heart rate is 120-250 bpm quite regular
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AVNRT may occur in healthy, young individualsmost commonly in women.
Most patients do not have structural heart disease. underlying heart condition
rheumatic heart disease,pericarditis, myocardial infarction, mitral valve prolapse, or preexcitation syndrome.
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Atrioventricular nodal reentrant tachycardia. heart rate 146 bpm with a normal axis.
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Patient is in sinus rhythm following atrioventricular nodal reentrant tachycardia
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ELECTROPHYSIOLOGY OF AV NODAL TISSUE AV nodal tissue is very important. In
most people, the AV node has a single conducting pathway that conducts impulses in an anterograde manner to depolarize the
bundle of His.
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One pathway (alpha) is a relatively slow conducting pathway with a short refractory period,
the second pathway (beta) is a rapid conducting pathway with a long refractory period. tachycardia.
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PREMATURE ATRIAL IMPULSE
premature atrial impulse.
slow pathway (alpha) in an anterograde manner;
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the impulse can then reenter the slow (alpha) pathway and initiate AVNRT
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Image A displays the slow pathway and the fast pathway, with a regular impulse being conducted through the atrioventricular node. Image B displays a premature impulse that is conducted in an anterograde manner through the slow pathway and in a retrograde manner through the fast pathway, as is seen in typical atrioventricular nodal tachycardia. Image C displays the premature impulse conducting in a retrograde manner through the pathway and the impulse reentering the pathway with anterograde conduction, which is seen commonly in patients with atypical atrioventricular nodal tachycardia.
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Image A displays the slow pathway
and the fast pathway, with a regular impulse being conducted
through the atrioventricular
node.
Image B displays a premature
impulse that is conducted in an
anterograde manner through
the slow pathway and in a
retrograde manner through the fast pathway,
as is seen in typical
atrioventricular nodal
tachycardia
. Image C displays the premature
impulse conducting in a
retrograde manner through the pathway and
the impulse reentering the pathway with anterograde
conduction, which is seen commonly in patients with
atypical atrioventricular
nodal tachycardia
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AVRT
AV REENTRANT TACHYCARDIA
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AV REENTRANT TACHYCARDIA AVRT is the result of 2 or more
conducting pathways: the AV node and 1 or more bypass tracts.
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In a normal heart, only a single route of conduction is present. Conduction begins at the sinus node, progresses to the AV node, and then to the bundle of His and the bundle branches.
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AVRT is associated with the Ebstein anomaly
Accessory pathways are errant strands of myocardium that bridge the mitral or tricuspid valves.
in AVRT, 1 or more accessory pathways connect the atria and the ventricles.
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The accessory pathways may conduct impulses in ananterograde manner,a retrograde manner,or both.
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ventricular preexcitation results.
This produces a short PR interval and a delta wave as is observed in persons with Wolff-Parkinson-White (WPW) syndrome
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Wolff-Parkinson-White pattern. Note the short PR interval and slurred upstroke (delta wave) to the QRS complexe
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Concealed accessory pathways are not evident during sinus rhythm, and they are only capable of retrograde conduction
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ORTHODROMIC AVRT.
A reentry circuit is most commonly established by impulses traveling in an anterograde manner through the AV node and in a retrograde manner through the accessory pathway; this is called orthodromic AVRT.
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ANTIDROMIC AVRT A reentry circuit may also be established
by a premature impulse traveling in an anterograde manner through a manifest accessory pathway and in a retrograde manner through the AV node; this is called antidromic AVRT
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The left image displays the atrioventricular node with the accessory pathway. The impulse is conducted in an anterograde manner in the atrioventricular node and in a retrograde manner in the accessory pathway. This circuit is known as orthodromic atrioventricular reentrant tachycardia and can occur in patients with concealed accessory tracts or Wolff-Parkinson-White syndrome. The right image displays the impulse being conducted in an anterograde manner through the accessory pathway and in a retrograde manner via the atrioventricular node. This type of circuit is known as antidromic atrioventricular reentrant tachycardia and only occurs in patients with Wolff-Parkinson-White syndrome. Both patterns may display retrograde P waves after the QRS complexes.
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The left image displays the atrioventricular node
with the accessory pathway. The impulse is
conducted in an anterograde manner in
the atrioventricular node and in a retrograde
manner in the accessory pathway. This circuit is known as orthodromic
atrioventricular reentrant tachycardia and can occur
in patients with concealed accessory
tracts or Wolff-Parkinson-White syndrome.
The right image displays the impulse being conducted in an
anterograde manner through the accessory
pathway and in a retrograde manner via the atrioventricular node. This type of circuit is known as antidromic atrioventricular reentrant tachycardia and
only occurs in patients with Wolff-Parkinson-White syndrome. Both patterns may display
retrograde P waves after the QRS complexes
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CLINICAL HISTORY
Palpitation - Greater than 96%
Dizziness - 75%
Shortness of breath - 47%
Syncope - 20%
Chest pain - 35%
Fatigue - 23%
Diaphoresis - 17%
Nausea - 13%
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PHYSICAL EXAMINATION
distressed.
Tachycardia
tachypneic
hypotensive.
Crackles secondary to heart failure.
S3
large jugular venous
pulsations
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DIFFERENTIAL DIAGNOSIS Atrial Fibrillation
Ventricular Fibrillation
Atrial Flutter
Ventricular Tachycardia
Atrial Tachycardia
Atrioventricular Nodal Reentry Tachycardia (AVNRT)
Sinus Node Dysfunction
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DIAGNOSIS
Electrocardiogram (ECG, EKG)—a test that records the heart’s activity by measuring electrical currents through the heartmuscle
Holter monitor or event monitor—an ambulatory monitor to record your heart rhythm that can be worn from 1-30 days to detect arrhythmias and correlate symptoms with the heart rhythm
Exercise test—particularly if the symptoms occur during physical activity
Electrophysiology study—an invasive test where monitoring wires are placed inside the heart and the heart's conduction system is tested directly
Cardiac catheterization —a tube-like instrument inserted into the heart through a vein or artery (usually in the arm or leg) to detect problems with the heart and its blood supply
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ECG
ECG characteristics of the various SVTs are as follows:
Sinus tachycardia - Heart rate greater than 100 bpm; P waves similar to sinus rhythm
Inappropriate sinus tachycardia - Findings similar to sinus tachycardia; P waves similar to sinus rhythm
Sinus node reentrant tachycardia - P waves similar to sinus rhythm; abrupt onset and offset
Atrial tachycardia - Heart rate 120-250 bpm; P-wave morphology different from sinus rhythm; long RP interval (in general); AV block does not terminate tachycardia
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Multifocal atrial tachycardia - Heart rate 100-200 bpm; 3 or more different P-wave morphologies
Atrial flutter- Atrial rate of 200-300 bpm; flutter waves; AV conduction of 2:1 or 4:1
Atrial fibrillation - Irregularly irregular rhythm; lack of discernible P waves
AV nodal reentrant tachycardia - Heart rate of 150-200 bpm; P wave located either within the QRS complex or shortly after the QRS complex; short RP interval in typical AVNRT and long RP interval in atypical AVNRT
AV reentrant tachycardia - Heart rate of 150-250 bpm; narrow QRS complex in orthodromic conduction and wide QRS in antidromic conduction; diagnosis excluded by AV block during SVT; P wave after QRS complex