Differential diagnosis[edit]

12 lead electrocardiogram showing a ventricular tachycardia (VT)

An electrocardiogram (ECG) is used to classify the type of tachycardia. They may be
classified into narrow and wide complex based on the QRS complex.[4] Presented
order of most to least common, they are:[4]

Narrow complex
Sinus tachycardia, which originates from the sino-atrial (SA) node, near the base
of the superior vena cava
Atrial fibrillation
Atrial flutter
AV nodal reentrant tachycardia
Accessory pathway mediated tachycardia
Atrial tachycardia
Multifocal atrial tachycardia
Junctional tachycardia
Wide complex
Ventricular tachycardia, any tachycardia that originates in the ventricles
Any narrow complex tachycardia combined with a problem with the conduction system
of the heart, often termed "supraventricular tachycardia with aberrancy"
A narrow complex tachycardia with an accessory conduction pathway, often termed
"supraventricular tachycardia with pre-excitation" (e.g. WolffParkinsonWhite
syndrome)
Pacemaker-tracked or pacemaker-mediated tachycardia
Tachycardias may be classified as either narrow complex tachycardias
(supraventricular tachycardias) or wide complex tachycardias. Narrow and wide refer
to the width of the QRS complex on the ECG. Narrow complex tachycardias tend to
originate in the atria, while wide complex tachycardias tend to originate in the
ventricles. Tachycardias can be further classified as either regular or irregular.

Sinus[edit]
Main article: Sinus tachycardia

The body has several feedback mechanisms to maintain adequate blood flow and blood
pressure. If blood pressure decreases, the heart beats faster in an attempt to
raise it. This is called reflex tachycardia. This can happen in response to a
decrease in blood volume (through dehydration or bleeding), or an unexpected change
in blood flow. The most common cause of the latter is orthostatic hypotension (also
called postural hypotension). Fever, hyperventilation, diarrhea and severe
infections can also cause tachycardia, primarily due to increase in metabolic
demands.

An increase in sympathetic nervous system stimulation causes the heart rate to

increase, both by the direct action of sympathetic nerve fibers on the heart and by
causing the endocrine system to release hormones such as epinephrine (adrenaline),
which have a similar effect. Increased sympathetic stimulation is usually due to
physical or psychological stress. This is the basis for the so-called fight-or-
flight response, but such stimulation can also be induced by stimulants such as
ephedrine, amphetamines or cocaine. Certain endocrine disorders such as
pheochromocytoma can also cause epinephrine release and can result in tachycardia
independent of nervous system stimulation. Hyperthyroidism can also cause
tachycardia.[5] The upper limit of normal rate for sinus tachycardia is thought to
be 220 bpm minus age.

Ventricular[edit]
Main article: Ventricular tachycardia
Ventricular tachycardia (VT or V-tach) is a potentially life-threatening cardiac
arrhythmia that originates in the ventricles. It is usually a regular, wide complex
tachycardia with a rate between 120 and 250 beats per minute.

Both of these rhythms normally last for only a few seconds to minutes (paroxysmal
tachycardia), but if VT persists it is extremely dangerous, often leading to
ventricular fibrillation.

Supraventricular[edit]
Main article: Supraventricular tachycardia
This is a type of tachycardia that originates from above the ventricles, such as
the atria. It is sometimes known as paroxysmal atrial tachycardia (PAT). Several
types of supraventricular tachycardia are known to exist.

Atrial fibrillation[edit]
Atrial fibrillation is one of the most common cardiac arrhythmias. In general, it
is an irregular, narrow complex rhythm. However, it may show wide QRS complexes on
the ECG if a bundle branch block is present. At high rates, the QRS complex may
also become wide due to the Ashman phenomenon. It may be difficult to determine the
rhythm's regularity when the rate exceeds 150 beats per minute. Depending on the
patient's health and other variables such as medications taken for rate control,
atrial fibrillation may cause heart rates that span from 50 to 250 beats per minute
(or even higher if an accessory pathway is present). However, new onset atrial
fibrillation tends to present with rates between 100 and 150 beats per minute.

AV nodal reentrant tachycardia[edit]

AV nodal reentrant tachycardia (AVNRT) is the most common reentrant tachycardia. It
is a regular narrow complex tachycardia that usually responds well to the Valsalva
maneuver or the drug adenosine. However, unstable patients sometimes require
synchronized cardioversion. Definitive care may include catheter ablation.

AV reentrant tachycardia[edit]
AV reentrant tachycardia (AVRT) requires an accessory pathway for its maintenance.
AVRT may involve orthodromic conduction (where the impulse travels down the AV node
to the ventricles and back up to the atria through the accessory pathway) or
antidromic conduction (which the impulse travels down the accessory pathway and
back up to the atria through the AV node). Orthodromic conduction usually results
in a narrow complex tachycardia, and antidromic conduction usually results in a
wide complex tachycardia that often mimics ventricular tachycardia. Most
antiarrhythmics are contraindicated in the emergency treatment of AVRT, because
they may paradoxically increase conduction across the accessory pathway.

Junctional tachycardia[edit]
Junctional tachycardia is an automatic tachycardia originating in the AV junction.
It tends to be a regular, narrow complex tachycardia and may be a sign of digitalis
toxicity.

Management[edit]
The management of tachycardia depends on its type (wide complex versus narrow
complex), whether or not the person is stable or unstable, and whether the
instability is due to the tachycardia.[4] Unstable means that either important
organ functions are affected or cardiac arrest is about to occur.[4]

Unstable[edit]
In those that are unstable with a narrow complex tachycardia, intravenous adenosine
may be attempted.[4] In all others immediate cardioversion is recommended.[4]

Terminology[edit]
The word tachycardia came to English from New Latin as a neoclassical compound
built from the combining forms tachy- + -cardia, which are from the Greek ta???
tachys, "quick, rapid" and ?a?d?a, kardia, "heart". As a matter both of usage
choices in the medical literature and of idiom in natural language, the words
tachycardia and tachyarrhythmia are usually used interchangeably, or loosely enough
that precise differentiation is not explicit. Some careful writers have tried to
maintain a logical differentiation between them, which is reflected in major
medical dictionaries[6][7][8] and major general dictionaries.[9][10][11] The
distinction is that tachycardia be reserved for the rapid heart rate itself,
regardless of cause, physiologic or pathologic (that is, from healthy response to
exercise or from cardiac arrhythmia), and that tachyarrhythmia be reserved for the
pathologic form (that is, an arrhythmia of the rapid rate type). This is why five
of the aforementioned dictionaries do not enter cross-references indicating
synonymy between their entries for the two words (as they do elsewhere whenever
synonymy is meant), and it is why one of them explicitly specifies that the two
words not be confused.[8] But the prescription will probably never be successfully
imposed on general usage, not only because much of the existing medical literature
ignores it even when the words stand alone but also because the terms for specific
types of arrhythmia (standard collocations of adjectives and noun) are deeply
established idiomatically with the tachycardia version as the more commonly used
version. Thus SVT is called supraventricular tachycardia more than twice as often
as it is called supraventricular tachyarrhythmia; moreover, those two terms are
always completely synonymousin natural language there is no such term as
"healthy/physiologic supraventricular tachycardia". The same themes are also true
of AVRT and AVNRT. Thus this pair is an example of when a particular prescription
(which may have been tenable 50 or 100 years earlier) can no longer be invariably
enforced without violating idiom. But the power to differentiate in an idiomatic
way is not lost, regardless, because when the specification of physiologic
tachycardia is needed, that phrase aptly conveys it.