TACHYCARDIA
ANUDYA KARTIKA
ACHMAD LEFI
CARDIOVASCULAR EMERGENCIES COURSE
INTRODUCTION
SVT is a common entity in clinical practice and a relatively
common occurrence in the emergency department.
Estimated incidence of 35 per 100,000 person-years,
with a prevalence of 2.29 per 1,000 persons AVNRT 50-60%,
AVRT 30%
Issa ZF, Miller JM, Zipes DP.Clinical arrhythmology and electrophysiology: a companion to Braunwalds heart disease 2nd ed.2012.
ELECTROPHYSIOLOGY
MECHANISM
All cardiac tachyarrhythmias are produced by one or more
mechanisms :
Disorders of
impulse
formation
Automaticity
Triggered
activity
Disorders of
impulse
conduction
Re-entry
AUTOMATICITY
Ability of cardiac cells to depolarize spontaneously, reach
threshold potential, & initiate a propagated action
potential in without of external electrical stimulation
Enhanced
automaticity
Abnormal
automaticity
TRIGGERED ACTIVITY
Impulse initiation in cardiac fibers caused by
afterdepolarizations that occur consequent to a preceding
impulse or series of impulses
RE-ENTRY
When a propagating impulse fails to die out after
normal activation of the heart and persists to
reexcite the heart after expiration of the refractory
period in repetitive cycles.
(A) An impulse (initiated from SA node) passes through AV nodal connection & an
accessory pathway.
(B) A premature atrial impulse occurs reaches recovering accessory pathway,
conduction can occur in the AV node.
(C) the impulse takes time to circulate through AV node & across the ventricle to
allow the acc. pathway to recover its excitability & conduct the impulse back to
the atrium
CARDIOVASCULAR EMERGENCIES COURSE
AVNRT
Most common type of SVT , mostly without any structural heart
disease.
The group most often affected is young, healthy women.
Some underlying heart disease pericarditis, previous
myocardial infarction, or mitral valve prolapse
The coexistence of slow and fast pathways in AV nodal tissue is
the basis of aberrant substrate for reentrant tachyarrhythmias
Issa ZF, Miller JM, Zipes DP.Clinical arrhythmology and electrophysiology: a companion to Braunwalds heart
disease 2nd ed. Elsevier Saunders 2012.
In typical AVNRT :
Antegrade conduction down the slow AV
nodal pathway & retrograde conduction up
the fast pathway
the retrograde P wave may not be seen or
may be visible early after the QRS complex.
When visible, it often appears as a pseudo R
wave in lead V1.
Issa ZF, Miller JM, Zipes DP.Clinical arrhythmology and
electrophysiology: a companion to Braunwalds heart disease
2nd ed. Elsevier Saunders 2012.
AVNRT ECG
P wave
QRS wave
P-QRS
Relationshp
AVRT
Caused by accessory pathways (or bypass
tracts) that serve as aberrant conduits for
impulses that pass from the SA node and travel
in an antegrade or retrograde fashion through
such tracts a reentry circuit.
Because the AV BT typically conducts faster than the AVN, the onset of
ventricular activation is earlier than if depolarization occurred only via the
AVN shortened PR (P-delta) interval.
Issa ZF, Miller JM, Zipes DP.Clinical arrhythmology andCARDIOVASCULAR EMERGENCIES COURSE
electrophysiology: a companion to Braunwalds heart disease
Bumi Surabaya Hotel, November 7-8th, 2015
2nd ed. Elsevier Saunders 2012.
ORTHODROMIC
AVRT
AVN-His Purkinje System serves as the anterograde limb of the
reentrant circuit (i.e., the pathway that conducts the impulse from
the atria to the ventricles), whereas an AV bypass tract serve sas
the retrograde limb
ORTHODROMIC AVRT
Rate
P wave
Inscribed within the ST-T wave segment with an RP interval that is usually less
than half of the tachycardia R-R interval (i.e., RP interval < PR interval)
QRS wave
ANTIDROMIC AVRT
An AV Bypass tract serves as the
anterograde limb ofthe reentrant circuit
QRS complex during antidromic AVRT is fully
preexcited (i.e., the ventricles are activated totally
by the BT with no contribution from the normal
conduction system).
Brady WJ, Truwit JD. Critical Decisions in Emergency & Acute Care Electrocardiography. Wiley Blackwell 2009.
P wave
wide (fully preexcited) QRS complex, usually regular R-R intervals, and
QRS wave ventricular rates of up to 250 beats/min.
CLINICAL
MANIFESTATIONS
Most often asymptomatic at the time of evaluation.
Significance
Focused
Physical
examination
Cardiovascular
Murmur (s)
Friction rub
Pericarditis
3rd Heart Sound
Heart failure tachycardia
Cannon waves
Possible AV Nodal
reentrant tachycardia or VT
Heart failure tachycardia
Respiratory
Crackle
Endocrine
Colucci RA, Silver MJ, Shubrook J. Common Types of Supraventricular Tachycardia : Diagnosis and Management.
CARDIOVASCULAR EMERGENCIES
Am Fam Physician. 2010;82(8):942-952
COURSE
Evaluation
System or test
In office
testing
Vitals
Hemodynamic
instability or
febrile illness
Incite
tachyarrhythmia
Orthostatic
blood pressure
Autonomic or
dehydration
issues
Induce
tachyarrhythmia
Electrocardiography
Preexcitation
Wolf-ParkinsonWhite Syndrome
Wide versus
narrow complex
QRS Complex
Q Waves
Ischemia VT
System or test
Possible finding
Significance
Blood work
Complete blood
count
Anemia or
infection
All possibly
induce or incite
tachyarrhythmias
Thyroid
stimulating
hormone
Suppression or
hyperthyroidism
Basic metabolic
panel
Electrolyte
disturbance
B-type
Natriuretic
peptide
Congestive HF
Cardiac enymes
MI or ischemia
Colucci RA, Silver MJ, Shubrook J. Common Types of Supraventricular Tachycardia : Diagnosis and Management.
Am Fam Physician. 2010;82(8):942-952
System or test
Possible finding
Significance
Cardiomegaly
Congestive HF
or
Cardiomyopathy
Holter monitor or
event recorder
Capture aberrant
rhythm, frequency,
duration
Type of
tachyarrhythmia
Graded exercise
test
Preexcitation or
aberrant rhythm
Type of
arrhythmia
Echocardiography
Structural or
valvular heart
disease
Possible
surgical
intervention
Colucci RA, Silver MJ, Shubrook J. Common Types of Supraventricular Tachycardia : Diagnosis and Management.
CARDIOVASCULAR EMERGENCIES
Am Fam Physician. 2010;82(8):942-952
COURSE
MANAGEMENT
A rapid assessment of the patients airway, breathing, and circulation
should be conducted, and all vital signs should be documented.
Nonpharmacologic
Pharmacologic
Electrical
modality/Catheter
ablation
MANAGEMENT
Non pharmacologic
The initial strategy for terminating a
PSVT a vagotonic maneuver
Reported complications
VF
hemiplegia
cervicomediastinal
hematoma.
Straining hypotension
MANAGEMENT
Pharmacologic
IV antiarrhythmic drugs should be administered for
arrhythmia termination in hemodynamically stable patients.
ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmiasexecutive summary. J Am
Coll Cardiol. 2003;42(8):1493-1531.
MANAGEMENT
Electrical Modality
Immediate DC cardioversion hemodynamically
unstable tachycardias
CARDIOVASCULAR
EMERGENCIES
COURSE
ACC/AHA/ESC guidelines for the management of patients with supraventricular
arrhythmiasexecutive
summary. J Am
Bumi Coll
Surabaya
November 7-8th, 2015
Cardiol.Hotel,
2003;42(8):1493-1531.
SUMMARY
Supraventricular tachycardia is a common entity in clinical practice and a
relatively common occurrence in the emergency department
ECG features can help to distinguish between atrioventricular nodal reentrant tachycardia and atrioventricular re-entrant tachycardia
THANK YOU