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SUPRAVENTRICULAR

TACHYCARDIA
ANUDYA KARTIKA
ACHMAD LEFI
CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

CASE : One day at the ED


A 24 - year - old man is brought to ED with sudden - onset
rapid palpitations associated with chest tightness, breathlessness and
feeling
dizzy
and
unwell.
It
started
30
minutes earlier, while playing football.
He is uncomfortable but alert and orientated. He is warm to touch and
looks well perfused.His BP is 92/55 mmHg, pulse 200 bpm, O2
saturations on 5 L/min via a face mask are 99% and his lung fields are
clear. The performed ECG was :

Cardiology: Clinical Cases Uncovered. By T. Betts, J. Dwight and


S. Bull. Published 2010 by Blackwell Publishing.

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WHATS THE LIKELY DX??


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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.

Supraventricular tachycardias are not usually associated


with structural heart disease, although there are exceptions.
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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

Tissues exhibiting abnormal automaticity that underlie SVT


in the atria, the AV junction, or vessels that communicate
directly with the atria (vena cava or pulmonary veins).
Issa ZF, Miller JM, Zipes DP.Clinical arrhythmology and
electrophysiology: a companion to Braunwalds heart disease.2012.

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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

accelerated generation of an action potential by


normal pacemaker tissue found in the sinus
node
latent pacemakers may become the functional
pacemaker under certain conditions.

only when there are major abnormalities in


myocyte transmembrane potentials in
particular steady-state depolarization of the
membrane potential (hypoxia, K+ imbalance)
Issa ZF, Miller JM, Zipes DP.Clinical arrhythmology and
electrophysiology: a companion to Braunwalds heart disease
2nd ed. Elsevier Saunders 2012.

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TRIGGERED ACTIVITY
Impulse initiation in cardiac fibers caused by
afterdepolarizations that occur consequent to a preceding
impulse or series of impulses

Issa ZF, Miller JM, Zipes DP.Clinical arrhythmology and


electrophysiology: a companion to Braunwalds heart disease 2nd ed.
Elsevier Saunders 2012.

DADs (Delayed Afterdepolarizations) occur after completion of repolarization of


the action potential (i.e., during phase 4).
EADs (Early Afterdepolarizations) occur during the action potential & interrupt
the orderly repolarization of the myocyte.
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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.

Delacrtaz E. Supraventricular tachycardia. N Engl J Med 2006;354:1039-51

(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
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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.

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Bumi Surabaya Hotel, November 7-8th, 2015

Issa ZF, Miller JM, Zipes DP.Clinical arrhythmology and electrophysiology: a companion to Braunwalds heart
disease 2nd ed. Elsevier Saunders 2012.

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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.

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AVNRT ECG

Sohinki D et al. The Ochsner Journal 14:586595, 2014

P wave

In typical (slow-fast) AVNRT P wave is usually not visible


because of the simultaneous atrial and ventricular activation
usually the same as in normal sinus rhythm.

QRS wave

P-QRS
Relationshp

In typical (slow-fast) AVNRT, the RP interval is very short (40 to


75 milliseconds).
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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.

Am Fam Physician. 2010;82(8):942-95

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WPW Kent accessory pathway


WPW pattern the constellation of ECG abnormalities
related to the presence of an AV BT (short PR interval, delta
wave) in asymptomatic patients.
WPW syndrome a WPW ECG pattern + tachyarrhythmias.

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

Issa ZF, Miller JM, Zipes DP.Clinical arrhythmology and


electrophysiology: a companion to Braunwalds heart disease
2nd ed. Elsevier Saunders 2012.

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ORTHODROMIC AVRT

Rate

tends to be a rapid tachycardia, with rates ranging from 150>250 beats/min.

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

generally normal and not preexcited, even when


preexcitation is present during SR

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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).

The Bypass tract involved in the antidromic AVRT circuit must be


capable of anterograde conduction preexcitation(wide QRS) is
typically observed during normal sinus rhythm.
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SVT of AVRT ECG

Brady WJ, Truwit JD. Critical Decisions in Emergency & Acute Care Electrocardiography. Wiley Blackwell 2009.

P wave

usually in the ST segment or T wave and is often visible between


successive R waves
negative in leads II, III, and aVF and a long RP interval (RP greater than
PR).

wide (fully preexcited) QRS complex, usually regular R-R intervals, and
QRS wave ventricular rates of up to 250 beats/min.

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CLINICAL
MANIFESTATIONS
Most often asymptomatic at the time of evaluation.

Fatigue, lightheadedness, chest discomfort, dyspnea, presyncope, or


more rarely, syncope.

Premature beats are commonly described as pauses or nonconducted


beats followed by a sensation of a strong heartbeat, or they are
described as irregularities in heart rhythm

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PHYSICAL EXAM &


DIAGNOSTIC WORKUP
Evaluation

System or test Possible finding

Significance

Focused
Physical
examination

Cardiovascular

Valvular heart disease


heart failure or
tachycardia

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

Enlarged or tender Hyperthyroidism or


thyroid gland
thyroiditis tachycardia

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

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Evaluation

System or test

Possible finding Significance

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

Type of SVT versus


VT

Q Waves

Ischemia VT

Colucci RA, Silver MJ, Shubrook J. Common Types of


Supraventricular Tachycardia : Diagnosis and
Management. Am Fam Physician. 2010;82(8):942-952

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

PHYSICAL EXAM &


DIAGNOSTIC WORKUP
Evaluation

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

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

PHYSICAL EXAM &


DIAGNOSTIC WORKUP
Evaluation

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

Diagnostics Chest radiography

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

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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

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ACC/AHA/ESC guidelines for the


management of patients with
supraventricular arrhythmias
executive summary.

J Am Coll Cardiol. 2003;42(8):1493-1531

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ACC/AHA/ESC guidelines for the management of patients with


supraventricular arrhythmias
executive summary.

J Am Coll Cardiol. 2003;42(8):1493-1531

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

ACC/AHA/ESC guidelines for the management of


patients with supraventricular arrhythmias
executive summary.

J Am Coll Cardiol. 2003;42(8):1493-1531

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Bumi Surabaya Hotel, November 7-8th, 2015

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MANAGEMENT
Non pharmacologic
The initial strategy for terminating a
PSVT a vagotonic maneuver

Carotid sinus massage


Coughing
Cold stimulus to the face
Straining

Evaluate CAROTID BRUIT (ie,


abnormal sound) before
attempting this maneuver (esp in
elderly).

Reported complications
VF
hemiplegia
cervicomediastinal
hematoma.
Straining hypotension

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MANAGEMENT
Pharmacologic
IV antiarrhythmic drugs should be administered for
arrhythmia termination in hemodynamically stable patients.

The advantage of adenosine relative to IV calcium-channel or beta


blockers relates to its rapid onset and short half-life.
ACC/AHA/ESC guidelines for the management of patients with
supraventricular arrhythmiasexecutive summary. J Am Coll
Cardiol. 2003;42(8):1493-1531.

CARDIOVASCULAR EMERGENCIES COURSE

Bumi Surabaya Hotel, November 7-8th, 2015

ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmiasexecutive summary. J Am
Coll Cardiol. 2003;42(8):1493-1531.

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Bumi Surabaya Hotel, November 7-8th, 2015

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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.

RHYTHM CONTROL : CATHETER ABLATION


percutaneous, catheter-based techniques designed to modify or
eliminate fast-pathway conduction.

Energy (initially diagnostic cath &


later RadioFrequency) was applied in the region of the apex of Koch's triangle,
along the superior aspect of the tricuspid annulus
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SUMMARY
Supraventricular tachycardia is a common entity in clinical practice and a
relatively common occurrence in the emergency department

Knowledge of the mechanism of each SVT is important in determining


management at the bedside.

ECG features can help to distinguish between atrioventricular nodal reentrant tachycardia and atrioventricular re-entrant tachycardia

The management consists of non-pharmacologic, pharmacologic, and


electrical modality (DC cardioversion & ablation catheter).

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THANK YOU

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