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Supraventricular tachycardia

Last updated: September 20, 2021

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Supraventricular tachycardias (SVTs) are a group of tachyarrhythmias arising from abnormalities in pacemaker activity and/or conduction involving myocytes of the atria and/or AV node. Types of SVT include atrioventricular nodal reentrant tachycardia (AVNRT; approx. two-thirds of cases), atrioventricular reciprocating (or reentrant) tachycardia (AVRT), focal atrial tachycardia (FAT), multifocal atrial tachycardia (MAT), and junctional tachycardia. AVNRT and AVRT are caused by abnormal conduction circuits that form an unending loop of conduction referred to as reentry. These reentry circuits can occur between parallel pathways within the AV node (as in AVNRT) or between the AV node and an accessory pathway of atrioventricular conduction (as in AVRT). Atrial tachycardias (FAT and MAT) and junctional tachycardias are usually the result of abnormal or ectopic pacemaker activity and do not involve reentry. The most common congenital accessory pathway (bundle of Kent) is seen in Wolff-Parkinson-White (WPW) syndrome and can cause ventricular preexcitation, in which supraventricular impulses bypass the AV node and are abnormally conducted to the ventricles, leading to a characteristic preexcitation pattern on ECG and a specific subset of preexcited tachyarrhythmias. SVTs have similar clinical features (typically paroxysms of tachycardia with dizziness, dyspnea, chest pain, or syncope) that may be self-limiting or progress to hemodynamic instability and sudden cardiac death. Common diagnostic steps include obtaining the patient's history and a 12-lead ECG to identify the type of SVT. The paroxysmal nature of SVTs means that continuous recording with a Holter monitor is often needed to confirm the diagnosis; in some cases, invasive electrophysiological studies (EP studies) may also be indicated. Management of SVT should be tailored to the patient. Hemodynamically unstable patients should undergo emergency cardioversion, while patients with acute SVT episodes that are hemodynamically stable may benefit from vagal maneuvers and/or antiarrhythmic medication (typically intravenous), depending on the underlying rhythm (see “Management of tachycardia”). Long-term management may involve antiarrhythmic medication or curative catheter ablation.

While atrial fibrillation and atrial flutter are types of supraventricular tachycardia, they are usually considered separately (see “Atrial fibrillation”).

General

Preexcitation

Epidemiology [2]

Clinical features [2][8]

For all patients with a new SVT, a 12-lead ECG, basic laboratory studies, and a TTE should be obtained. Further testing depends on patient risk factors but may include exercise tolerance testing or myocardial ischemia testing. An EP study can be used for simultaneous diagnosis and treatment. [8]

Initial diagnostics [8]

Additional diagnostics [8]

Differential diagnoses

Although differentiating between types of SVT can be challenging and may require EP studies to confirm the diagnosis, some ECG features may help to differentiate diagnoses.

Patients with SVT symptoms are frequently misdiagnosed with anxiety or panic disorders. Paroxysmal tachycardia should be ruled out before making a psychiatric diagnosis to avoid anchoring bias.

For clinically oriented algorithms of acute management of tachycardia see “Management of unstable tachycardia with a pulse” and “Management of undifferentiated SVT”. This section provides an overview of the management of SVT. The dedicated sections of this article (e.g., AVNRT) contain more specific information.

General principles

Vagal maneuvers

Valsalva maneuver

Modified Valsalva maneuver [11]

  • Patient sits in a semirecumbent position
  • Blows into a 10 mL syringe for 15 seconds (moving the plunger up achieves a strain of ∼ 40 mm Hg) [12]
  • Afterwards the patient is laid supine and the legs are passively elevated to 45° for 15 seconds.
  • Return to the semirecumbent position for 45 seconds before reassessing rhythm

Carotid sinus massage [13]

Diving reflex

  • Traditionally involves immersing the head in cold water, which is uncomfortable for most patients
  • Can be limited to applying a bag of ice water to the face (particularly the forehead and nasal area) for ∼ 10 seconds [15]

Do not simultaneously apply bilateral carotid artery pressure because this can impede cerebral blood flow.

Medical therapy

See “Management of undifferentiated SVT” for a clinically oriented algorithmic approach and the dedicated sections of this article (e.g., “Treatment of AVNRT”) for more specific information.

Catheter ablation

  • Description
    • Radiofrequency or cryothermal energy is applied via a cardiac catheter to eliminate aberrant pathways or impulses from arrhythmogenic foci.
    • Usually performed in conjunction with an EP study
  • Indications [2]
    • Curative therapy in AVNRT, AVRT with concealed pathway, or drug-refractory AT
    • Symptomatic patients who want to avoid long-term drug therapy (especially younger patients)
    • Asymptomatic patients with special lifestyle considerations (e.g., pilots)

Definition

  • A tachyarrhythmia caused by a dysfunctional AV node that contains two electrical pathways, which form a reentry circuit

Pathophysiology

  • The AV node contains two electrical pathways, one fast and one slow → the electrical impulse circles around the AV node within both pathways → a continuous circuit conducts impulses to the ventricles → tachycardia
  • Approx. 90% of cases are due to anterograde conduction across the slow-conducting pathway and retrograde conduction in the fast pathway (although the reverse is possible).

ECG findings in AVNRT [16][17]

Treatment of AVNRT

Acute management

Long-term management

Definition

Pathophysiology

  • Accessory pathways may be manifest or concealed. [8][21]
    • Manifest pathways
      • Can conduct in both anterograde (atrium to ventricle) and retrograde (ventricle to atrium) directions
      • Anterograde conduction is more common and leads to preexcitation seen on the ECG in sinus rhythm. [21]
    • Concealed pathways
      • Can conduct only in a retrograde direction
      • Not visible on ECG in sinus rhythm
  • There are two types of atrioventricular reciprocating tachycardia; the direction of the impulses help distinguish between them.

Do not confuse atrioventricular reentrant (or reciprocating) tachycardia (AVRT) with atrioventricular nodal reentrant tachycardia (AVNRT)! AVRT is caused by an accessory pathway, whereas in AVNRT there are two functional pathways within the AV node.

ECG findings

ECG findings in AVRT [8][25][26]
Orthodromic AVRT
Antidromic AVRT

Treatment of AVRT

Acute episodes

Long-term management [2]

Definitions

Pathophysiology

Epidemiology

ECG findings in WPW

Treatment of WPW

Acute episodes

AV nodal blocking agents and vagal maneuvers are contraindicated in patients with ventricular preexcitation and the following underlying tachyarrhythmias: Afib, atrial flutter, FAT, and MAT.

Long-term management [2][32]

Management of WPW pattern and WPW syndrome depends on underlying risk factors and patient preference.

Risk stratification in WPW syndrome [36]

Risk stratification is determined by a cardiologist based on clinical, ECG, and electrophysiological parameters.

High-risk patients

Catheter ablation of the accessory pathway should be offered to all patients. [2]

Low-risk patients [2]

Definition

Etiology [38]

Pathophysiology [39][40]

ECG findings [2][42]

An isoelectric baseline between P waves can help distinguish focal AT from atrial flutter. [43]

Treatment [2]

Acute episodes

Episodes of FAT are most commonly self-limiting and asymptomatic, in which case they do not require treatment.

Avoid AV nodal blockers in patients with preexcited FAT (e.g., due to WPW) because they can trigger ventricular arrhythmias.

Long-term management

Definition

  • An irregular SVT featuring ≥ 3 morphologies of P waves [2]

Etiology [47][48]

Pathophysiology [50]

  • Multifocal origin of pacemaker activity
  • Mechanism remains unclear [47]
  • Often associated with right atrial enlargement

ECG findings [47]

Do not confuse MAT with atrial fibrillation. In Afib, there are no distinct or organized P waves, whereas in MAT there are distinct P waves with varying morphologies.

Unlike in atrial flutter, in MAT there are distinct isoelectric intervals between P waves.

Treatment of multifocal atrial tachycardia [2][8][51]

Treatment of MAT is challenging and specialists should be involved early. Patients often have severe underlying conditions and rhythm control and electrical cardioversion are not effective. For clinically-oriented management algorithms for patients with tachycardia, see “Management of tachycardia”.

Avoid AV nodal blockers in patients with preexcited MAT (e.g., due to WPW) because of the risk of ventricular arrhythmias.

Avoid electrical cardioversion and antiarrhythmic drugs (e.g., procainamide, lidocaine, phenytoin), as they are not effective in treating MAT. [2][51]

Definition

Etiology [2]

Pathophysiology [2][8]

ECG findings [2][55]

While the rate varies between paroxysmal junctional tachycardia and accelerated AV junctional rhythm, the ECG appearance is otherwise similar.

Treatment of junctional tachycardia [2]

These recommendations are for confirmed junctional tachycardia. For clinically-oriented management algorithms for patients with tachycardia, see “Management of tachycardia.”

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