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Supplement

Diagnosis of Supraventricular Tachycardia

N Al-Rawahi, MS Green

his is a review of the recent knowledge regarding the diagnosis of various forms of supra-ventricular tachycardia (SVT). SVT are the most common tachycardia facing a physician with a wide range of risk ranging from the most benign to the most malignant type of tachyarrhythmia. A proper approach to the diagnosis of SVT will affect mode of treatment, and ultimately the morbidity and even the mortality of the patients. Firstly, we must define 2 terms; SVT and narrow complex tachycardia. All narrow complex tachycardia are SVT. SVT most of the time are narrow complex but can be wide complex in two situations: 1) aberrant conduction due to functional or preexistent bundle branch block or 2) preexcited tachycardia in the presence of anterograde accessory pathway conduction.

distinguishes it clinically from ST.1 Episodes of SNRT may vary in length. It can be sustained and even incessant.3 The ECG will show a tachycardia (usually between 100 150 /min) with normal P wave morphology. The key feature in differentiating this from sinus tachycardia is the nonparoxysmal behaviour. Focal Atrial tachycardia (FAT): This is a regular atrial rhythm at a constant rate of >100 beats per min originating outside of the sinus node.4 It may be sustained or terminate spontaneously.5 The ECG will show P waves that have an abnormal morphology and/or axis. The P wave morphology is not always reliable in localizing the atrial focus, although a narrow P wave does suggest a septal origin. P wave morphology depends on both on the arrhythmogenic site and on intraatrial conduction6,7 (Fig. 1). Multifocal atrial tachycardia (MAT): The average age of presenting patients is approximately 70 years. These patients are generally quite ill, with pulmonary, cardiac, and other serious diseases. It has been estimated to occur in 0.05 to 0.32 percent of electrocardiograms in general hospitals.8-12 MAT is an ECG diagnosis and requires the following criteria:8,9 1. 2. 3. 4. Discrete P waves with at least three different morphologies. An atrial rate of over 100 beats/min. The P waves are separated by isoelectric intervals. The P-P intervals, the P-R duration, and the R-R intervals vary (irregular).

Classifications
Many classifications have been used for SVT. One of the practical classifications is to divide them according to the structures required to initiate and maintain the tachycardia. By this classification there are two types of SVT, those which require only atrial tissue for their initiation and maintenance, and those that require the atrioventricular (AV) junction (Table 1). This classification is more relevant and in keeping with the electrophysiological assessment of the tachycardia.

SVT OnLY rEQUIrIng AtrIaL tIssUE FOr InItIatIOn and maIntEnancE

Sinus tachycardia (ST): In this type of tachycardia the patient will be having a heart rate more than 100 /min. The most common causes of ST are in response to exercise and in conditions in which catecholamine release is physiologically enhanced as in anger, stress, flight, or fright. ST is not a paroxysmal condition but manifests a gradual increase and decrease in rate.1 The ECG will show a P wave as in normal SR. The PR interval will generally shorten as the rate increases. Sometimes with very fast heart rates (more than 150/min) the P wave may be difficult to see as it will be imposed in the T wave of the previous beat. This may bring lead to confusion in diagnosis. Manoeuvres such as carotid sinus massage or Valsalva may be helpful in determining the P wave position. Sinus nodal reentrant tachycardia (SNRT): This is an uncommon arrhythmia. 2 It has an abrupt onset and termination which

MAT usually progress into other types of atrial tachycardia. In one study 55% of patients progressed into atrial flutter or atrial fibrillation.10 Atrial fibrillation (AF): AF occurs in the normal heart (lone AF), and in the presence of organic heart disease of any cause. It is classified into: paroxysmal, persistent and permanent according to the duration of the tachycardia13 (Fig. 2). AF is associated with the following ECG changes: 1. 2. Absent P waves. Fibrillatory or f waves are present at a rate that is usually between 350 and 600 beats/minute; the f waves vary in morphology, amplitude, and intervals. R-R intervals are irregularly irregular. The heart rate may vary depending on the AV node.

3. 4.

Table 1 : Classification of SVT by structures required for initiation and maintenance

Atrial tissue only Sinus tachycardia (ST) Sinus nodal reentrant tachycardia (SNRT) Focal Atrial tachycardia (FAT) Multifocal atrial tachycardia (MAT) Atrial fibrillation (AF) Atrial flutter (AFl) AV junction AV nodal reentrant tachycardia(AVNRT) Atrioventricular reentrant tachycardia (AVRT)

Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin, Ottawa, Ontario, K1Y4W7, Canada.

Fig.1: Atrial Tachycardia with 2:1 conduction. ECG of a 50 year old man with palpitation. See abnormal P waves in lead II and V1 at a rate of 200/min with QRS rate of 100 /min.

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Fig. 2: Atrial Fibrillation. ECG of a 62 year woman. Clear irregular irregular QRS complexes with no defined P wave. Atrial flutter (AFl): AFl may be a stable rhythm or a bridge arrhythmia between sinus rhythm and atrial fibrillation. It is an arrhythmia most commonly seen in men, the elderly and individuals with preexisting structural heart disease or chronic obstructive lung disease.14 It is a macroreentrant type of tachycardia generally utilizing right atrial tissue. The ventricular conduction rate is variable (2:1 or 4:1) depending on the conduction in the AV node. There are two distinct types of atrial flutter: Type one or typical also called counterclockwise, and type two or atypical also called clockwise.4,15 Diagnostic ECG features of both are listed in Table 2 (Figs. 3 and 4).

Fig. 4: Atrial Flutter Type two. ECG of 60 year old man. Note the positive F waves in leads II, III and aVF. There is variable AV block. requires dual conduction physiology in the AV node; a so-called fast pathway and a slow pathway (Fig. 5). The ECG features of typical AVNRT (slow-fast) are: 1. 2. 3. Rate of 120 to 220 /minute. P wave buried in the QRS complex or occurring slightly before or after (short RP) and usually in fusion with the QRS complex. Inverted P waves in leads I, II, III and aVF.

SVT rEQUIrIng AV JUnctIOn FOr InItIatIOn and maIntEnancE

AV nodal reentrant tachycardia (AVNRT): This is a common arrhythmia, accounting for approximately two thirds of cases of paroxysmal SVT. It is paroxysmal and recurrent which can develop in the normal heart or in the presence of organic heart disease. AVNRT can present at any age. In a study of 253 patients, the mean age of symptom onset in AVNRT was 32 years, with two thirds of cases beginning after the age of 20 years .16 It is a microreentrant tachycardia that utilizes the AV node and, usually, perinodal atrial tissue.17,18 It

Atypical or fast-slow AVNRT has a long RP interval and may be difficult to distinguish from orthodromic AVRT conducting down the AV node and up a slowly conducting accessory pathway by the surface ECG.19 Atrioventricular reentrant tachycardia (AVRT): It is less common than AVNRT and the patients usually younger. The mean age of symptom onset of 23 years and around 40% of patients had the initial onset of symptoms after the age of 20.16 One main type of AVRT is WPW syndrome. AVRT uses two distinct pathways, the normal AV conduction system and an AV accessory pathway. Keeping this in mind there will be two ways the conduction will travel. The first most common variety occurs when the impulses travel down the AV node to the ventricle and up the accessory pathway (AP). This is called orthodromic AV reentry tachycardia. The second type occurs when the AP is used in the anterograde direction to the ventricle and retrograde conduction occurs up the AV node. This is called antidromic AV reentry tachycardia. Both can be initiated by atrial or ventricular

Table 2 : ECG features type one and type two atrial flutter
Type one AFl Absent P waves Biphasic sawtooth flutter waves (F waves) range between 240 to 340 beats/min The F waves have an axis of 90o and typically are prominently negative in the inferior leads (II, III, aVF) & V1 Type two AFl Absent P waves Biphasic flutter waves (F waves) ranging from 340 to 440 beats/min. Positive F waves recorded in the inferior leads

Fig. 3 : Atrial Flutter Type one. ECG of a 55 year old man. A clear biphasic sawtooth F waves in leads II and aVF with 2:1 AV block.

Fig.5 : AVNRT. ECG of 27 year old woman with palpitations. Narrow complex tachycardia at a rate of 200 / min. Note the P waves in the terminal portion of the QRS complex (best seen in lead V1, magnified at bottom).

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premature beats. The ECG features of both are: 1. Orthodromic AVRT: The heart rate is regular and ranges between 150 to 220/min. The P wave is visible and inscribed within the ST-T wave segment. The RP interval is shorter than PR interval and constant. The QRS in narrow20 (Fig. 6). Antidromic AVRT: The heart rate is regular and ranges between 150 to 220/min. It is characterized by a pre-excited wide QRS complex. The P wave may be more difficult to see because of the wide QRS and ST and T wave. When the P wave is easily visible the RP interval is constant and may be longer than the PR interval, secondary to slow retrograde conduction over the AV node.20 Rarely, in patients with more than one tachycardia the circuit may use one AP in the anterograde direction and another AP in the retrograde direction. This tachycardia may be virtually impossible to distinguish from typical antidromic AVRT. Fig. 7 : Pre-excited Atrial fibrillation. ECG of a 25 year old man patient known for WPW syndrome presented with palpitation and syncope. Notice the irregularly irregular rhythm with bizarre nature of the QRS complexes. 3. likely AV nodal independent rarely could be AVNRT; absolutely rules out AVRT! usually atrial fib or flutter with variable block Sometimes multifocal atrial tachycardia

2.

The most frightening tachycardia in patients with pre-excitation is AF. Development of AF in combination with a short anterograde refractory period of the AP may initiate ventricular tachycardia or fibrillation (called atrioventricular fibrillation)21 (Fig. 7). The ECG features include: 1. 2. 3. Irregularly irregular rhythm. Rapid ventricular rate more than 180 to 200 /min, occasionally with R-R intervals <200 msec. QRS complexes are wide and bizarre, and not resembling typical bundle branch block aberrancy.

Irregularity:

PractIcaL apprOacH tO SVT

In real life the physician will be faced by a patient with a tachycardia. The above knowledge will be needed to figure out what type the tachycardia the patient has. It is common that only the response to treatment will give the physician the clue about the diagnosis. With the above knowledge the following steps usually help in diagnosing SVT: 1. 2. P wave position PR<RP
Usually

REFErEncEs
1. 2. 3. Josephson ME. Clinical Cardiac Electrophysiology: Techniques and Interpretations. 2nd ed, Lea Febiger, Philadelphia, 1993. Gomes JA, Mehta D, Langan MN. Sinus node reentrant tachycardia. Pacing Clin Electrophysiol 1995;18(5 Pt 1):1045-57. Gomes JA, Hariman RJ, Kang PS, Chowdry IH. Sustained symptomatic sinus node reentrant tachycardia: incidence, clinical significance, electrophysiologic observations and the effects of antiarrhythmic agents. J Am Coll Cardiol 1985;5:45-57. Saoudi N, Cosio F, Waldo A, Chen SA, Iesaka Y, Lesh M, Saksena S, Salerno J, Schoels W. A classification of atrial flutter and regular atrial tachycardia according to electrophysiological mechanisms and anatomical bases; a Statement from a Joint Expert Group from The Working Group of Arrhythmias of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Eur Heart J 2001;22:1162-82. Chen SA, Chiang CE, Yang CJ, Cheng CC, Wu TJ, Wang SP, Chiang BN, Chang MS. Sustained atrial tachycardia in adult patients. Electrophysiological characteristics, pharmacological response, possible mechanisms, and effects of radiofrequency ablation. Circulation 1994;90:1262-78. MacLean WA, Karp RB, Kouchoukos NT, James TN, Waldo AL. P waves during ectopic atrial rhythms in man: a study utilizing atrial pacing with fixed electrodes. Circulation 1975;52:426-34. Wu D, Denes P, Leon FA, Chhablani RC, Rosen KM. Limitation of the surface electrocardiogram in diagnosis of atrial arrhythmias. Further observations on dissimilar atrial rhythms. Am J Cardiol 1975;36:91-7. Kastor JA. Multifocal atrial tachycardia. N Engl J Med 1990;322:1713-7. Shine, KI, Kastor, JA, Yurchak, PM. Multifocal atrial tachycardia: Clinical and electrocardiographic features in 32 patients. N Engl J Med 1968; 279:344.

atrial tachycardia, but can be unusual variety of AVRT or AVNRT (or AVNRT)

RP < PR
Usually AVRT

4.

Can be atrial tachycardia with a long PR interval

Continuation of tachycardia at atrial level despite AV block (by vagal stimulation or intravenous adenosine) : 5.

6.

7.

8. 9.

Fig. 6 : Orthodromic AVRT: ECG of 23 year old man with WPW syndrome during tachycardia. Note the P wave with in the ST-T wave best seen in V1 (magnified at bottom).

10. Lipson MJ, Naimi S. Multifocal atrial tachycardia (chaotic atrial tachycardia). Clinical associations and significance. Circulation 1970;42:397. 11. Phillips J, Spano J, Burch G. Chaotic atrial mechanism. Am Heart J 1969;78:171.

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12. Kones RJ, Phillips JH, Hersh J. Mechanism and management of chaotic atrial mechanism. Cardiology 1974;59:92. 13. Fuster V, Ryden LE, Asinger RW, et al. ACC/AHA/ESC guidelines for the management of patients with atrial fibrillation: executive summary. A Report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines and Policy Conferences (Committee to Develop Guidelines for the Management of Patients With Atrial Fibrillation) Developed in Collaboration With the North American Society of Pacing and Electrophysiology. J Am Coll Cardiol 2001;38:1231. 14. Granada J, Uribe W, Chyou PH, Maassen K, Vierkant R, Smith PN, Hayes J, Eaker E, Vidaillet H. Incidence and predictors of atrial flutter in the general population. J Am Coll Cardiol 2000;36:22426. 15. Wells JL Jr, MacLean WA, James TN, et al. Characterization of atrial flutter. Studies in man after open heart surgery using fixed atrial electrodes. Circulation 1979;60:665. 16. Goyal R, Zivin A, Souza J, Shaikh SA, Harvey M, Bogun F, Daoud E, Man KC, Strickberger SA,Morady F. Comparison of the ages of tachycardia onset in patients with atrioventricular nodal reentrant tachycardia and accessory pathway-mediated tachycardia. Am Heart J 1996;132:765-7. 17. McGuire MA, Bourke JP, Robotin MC, Johnson DC, MeldrumHanna W, Nunn GR, Uther JB, Ross DL. High resolution mapping of Kochs triangle using sixty electrodes in humans

with atrioventricular junctional (AV nodal) reentrant tachycardia. Circulation 1993;88(5 Pt 1):2315-28. 18. McGuire MA, Janse MJ, Ross DL. AV nodal reentry: Part II: AV nodal, AV junctional, or atrionodal reentry? J Cardiovasc Electrophysiol 1993;4:573-86. 19. Pieper SJ, Stanton MS. Narrow QRS complex tachycardias. Mayo Clin Proc 1995;70:371-5. 20. Cain ME, Luke RA, Lindsay BD. Diagnosis and localization of accessory pathways. Pacing Clin Electrophysiol 1992;15:801. 21. Yee, R, Klein, GJ, Sharma, AD, Zipes, DP, Jalife, J (Eds), et al. Tachycardia associated with accessory atrioventricular pathways. In: Cardiac Electrophysiology, WB Saunders, Philadelphia 1990. p.463.