Narrow-complex tachycardia: Difference between revisions
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==Background== | |||
*Heart rate > 100 bpm | |||
*Originates above the ventricles | |||
==Clinical Features== | |||
*Heart rate > 100 bpm | |||
*May have: | |||
**[[Palpitations]] | |||
**[[Syncope]] or pre-syncope | |||
**[[Chest pain]] | |||
**[[Dyspnea]] | |||
**[[Altered level of consciousness]] | |||
**Delayed capillary refill | |||
==Differential Diagnosis== | |||
{{Tachycardia (narrow) DDX}} | |||
{{Tachycardia (wide) DDX}} | |||
==Evaluation== | ==Evaluation== | ||
{| class="wikitable" | {| class="wikitable" | ||
|- | |- | ||
Line 15: | Line 32: | ||
| Incr. AV block | | Incr. AV block | ||
|- | |- | ||
| A Flutter | | [[A Flutter]] | ||
| Regular | | Regular | ||
| >250, <350 | | >250, <350 | ||
Line 27: | Line 44: | ||
| Nothing | | Nothing | ||
|- | |- | ||
| | | [[AVNRT]] (SVT) | ||
| Regular | | Regular | ||
| >160 | | >160 | ||
| No p's | | No p's | ||
| | | → NSR | ||
|- | |- | ||
| Junctional | | Junctional | ||
Line 39: | Line 56: | ||
| Nothing | | Nothing | ||
|- | |- | ||
| MAT | | [[MAT]] | ||
| Irregular | | Irregular | ||
| >100 | | >100 | ||
| >3 p shapes | | >3 distinct p shapes | ||
| Transient slowing | | Transient slowing | ||
|- | |- | ||
| Sinus | | [[Sinus tachycardia]] | ||
| Regular | | Regular | ||
| | | | ||
Line 57: | Line 74: | ||
==Management== | ==Management== | ||
{{ACLS Narrow Regular Tachycardia}} | |||
{{ACLS Narrow Irregular Tachycardia}} | |||
===[[ | ===[[Atrial fibrillation with RVR]]/flutter=== | ||
*Rate control: | *Rate control: [[Diltiazem]], [[metoprolol]], [[digoxin]] | ||
**Dig usually only helpful when already with a block (e.g. 2:1) | **Dig usually only helpful when already with a block (e.g. 2:1) | ||
*Cardioversion: Sotalol, | *Cardioversion: [[Sotalol]], [[cardioversion|electric]] | ||
=== | ===[[Junctional tachycardia]]=== | ||
* | *Treat underlying cause | ||
*Consider: | |||
**[[Amiodarone]] | |||
**[[Beta-blocker]] | |||
**[[Calcium-channel blocker]] | |||
== | ==Disposition== | ||
*Stable patients without serious comorbid illness who are adequately rate or rhythm controlled can be discharged home with follow-up | |||
*Patients with acute underlying cause may require admission | |||
*Patients who cannot achieve asymptomatic rate or rhythm control may require admission | |||
* | |||
* | |||
==See Also== | ==See Also== | ||
*[[Tachycardia]] | |||
*[[ACLS: Tachycardia]] | *[[ACLS: Tachycardia]] | ||
*[[V Tach vs. SVT]] | *[[V Tach vs. SVT]] | ||
*[[SVT]] | *[[SVT]] | ||
*[[Atrial Fibrillation (RVR)]] | *[[Atrial Fibrillation (RVR)]] | ||
==External Links== | |||
==References== | |||
<references/> | |||
[[Category:Cardiology]] | [[Category:Cardiology]] |
Latest revision as of 18:47, 17 April 2024
Background
- Heart rate > 100 bpm
- Originates above the ventricles
Clinical Features
- Heart rate > 100 bpm
- May have:
- Palpitations
- Syncope or pre-syncope
- Chest pain
- Dyspnea
- Altered level of consciousness
- Delayed capillary refill
Differential Diagnosis
Narrow-complex tachycardia
- Regular
- AV Node Independent
- Sinus tachycardia
- Atrial tachycardia (uni-focal or multi-focal)
- Atrial fibrillation
- Atrial flutter
- Idiopathic fascicular left ventricular tachycardia
- AV Node Dependent
- AV Node Independent
- Irregular
- Multifocal atrial tachycardia (MAT)
- Sinus tachycardia with frequent PACs, PJCs, PVCs
- Atrial fibrillation
- Atrial flutter with variable conduction
- Digoxin Toxicity
Wide-complex tachycardia
Assume any wide-complex tachycardia is ventricular tachycardia until proven otherwise (it is safer to incorrectly assume a ventricular dysrhythmia than supraventricular tachycardia with abberancy)
- Regular
- Monomorphic ventricular tachycardia
- PSVT with aberrant conduction:
- PSVT with bundle branch block^
- PSVT with accessory pathway
- Atrial flutter with bundle branch block^
- Sinus tachycardia with bundle branch block^
- Accelerated idioventricular rhythm (consider if less than or ~120 bpm)
- Metabolic
- Irregular
- Atrial fibrillation/atrial flutter with variable AV conduction AND bundle branch block^
- Atrial fibrillation/atrial flutter with variable AV conduction AND accessory pathway (e.g. WPW)
- Atrial fibrillation + hyperkalemia
- Polymorphic ventricular tachycardia
^Fixed or rate-related
Evaluation
Differential | A.Rhythm | A.rate | A.morphology | Vagal/adenosine |
A fib | Irregular | >350 | Fibrillatory (V1) | Incr. AV block |
A Flutter | Regular | >250, <350 | Sawtooth (II, III, AVF) | Incr. AV block |
A Tach | Regular | >100 | Neg in II, III, AVF | Nothing |
AVNRT (SVT) | Regular | >160 | No p's | → NSR |
Junctional | Regular | >100, <150 | No p's or retrograde p's | Nothing |
MAT | Irregular | >100 | >3 distinct p shapes | Transient slowing |
Sinus tachycardia | Regular |
>100 <180 |
Normal | Transient slowing |
Flutter vs coarse AFib: determine atrial regularity by taking big bites
Management
Narrow Regular Tachycardia
- Sinus tachycardia
- Treat underlying cause
- SVT
- Vagal maneuvers (convert up to 25%)
- Adenosine 6mg rapid IV push if patient hemodynamically stable (unstable should proceed directly to electrical cardioversion)
- Can follow with repeat dose of 6 mg or 12mg if initially fails
- If adenosine fails, initiate rate control with calcium channel blocker or beta blocker or use synchronized cardioversion
- Diltiazem 15-20mg IV, followed by infusion of 5-15mg/hr
- Metoprolol 5mg IVP x 3 followed by 50mg PO
- Synchronized cardioversion (50-100J)
- Provide sedation prior to synchronized cardioversion if patient is hemodynamically stable
- Atrial flutter
- Stable: Consider rate control to HR < 110 bpm
- Unstable: Synchronized cardioversion; start at 50J
Narrow Irregular Tachycardia
- Multi-focal atrial tachycardia (MAT)
- Treat underlying cause (hypokalemia, hypomagnesemia)
- Consider diltiazem
- Avoid beta blockers unless they are already known to be tolerated, as airway disease often co-morbid
- If not symptomatic and rate < 110/120 bpm, may not require treatment (e.g., patient with MAT secondary to COPD)
- Sinus Tachycardia with frequent PACs
- Treat underlying cause
- A fib / A Flutter with variable conduction (see also Atrial Fibrillation with RVR)
- Check if patient has taken usual rate-control meds
- If missed dose, may provide dose of home medication and observe for resolution
- Determine whether patient is better candidate for rate control or rhythm control [1]
- Rate control preferred with:
- Persistent A fib
- Less symptomatic patients
- Age 65 or older
- Hypertension
- No heart failure
- Previous failure to cardiovert
- Patient preference
- Rhythm control preferred with:
- Paroxismal or new A fib
- More symptomatic patients
- Age < 65 years
- Heart failure clearly exacerbated by A fib
- No history of rhythm control failure
- Patient preference
- Rate control preferred with:
- Rate control with:
- Diltiazem
- Metoprolol
- Amiodarone (good in setting of hypotension, CHF)
- Digoxin (good in setting of CHF)
- Rhythm conversion with:
- Synchronized Cardioversion (120-200 J)
- Best performed on patients with new onset A fib or patients fully therapeutically anti-coagulated for > 3 weeks
- Procainamide per Ottawa Aggressive ED Cardioversion Protocol
- Synchronized Cardioversion (120-200 J)
- Check if patient has taken usual rate-control meds
Atrial fibrillation with RVR/flutter
- Rate control: Diltiazem, metoprolol, digoxin
- Dig usually only helpful when already with a block (e.g. 2:1)
- Cardioversion: Sotalol, electric
Junctional tachycardia
- Treat underlying cause
- Consider:
Disposition
- Stable patients without serious comorbid illness who are adequately rate or rhythm controlled can be discharged home with follow-up
- Patients with acute underlying cause may require admission
- Patients who cannot achieve asymptomatic rate or rhythm control may require admission
See Also
External Links
References
- ↑ Frankel, G. et al. (2013) Rate versus rhythm control in atrial fibrillation. Canadian Family Physician 59(2), 161 - 168