Supraventricular Tachycardia - Life in The Fast Lane ECG Library

6/9/2016
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Supraventricular Tachycardia (SVT)

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Background
The term supraventricular tachycardia(SVT), whilst often used synonymously with
AV nodal re-entry tachycardia (AVNRT), can be used to refer toany

tachydysrhythmia arising from above the level of the Bundle of His.
Different types of SVT arise from or are propagated by the atria or AV node,
typicallyproducing a narrow-complex tachycardia (unless aberrant conduction is
present).
Paroxysmal SVT (pSVT) describes an SVT with abrupt onset and offset
characteristically seen with re-entrant tachycardias involving the AV node such as
AVNRT or atrioventricular re-entry tachycardia (AVRT).
http://lifeinthefastlane.com/ecglibrary/svt/
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Supraventricular tachycardia
Classication
SVTs can be classied based on site of origin(atria or AV node)or regularity

(regular or irregular).
Classication based on QRS width is unhelpful as this is also inuenced by the
presence of pre-existing bundle branch block, rate-related aberrant conduction or
presence of accessory pathways.
Classication of SVT by site of origin and regularity
Regular
Atrial
Atrioventricular
Irregular
Sinus tachycardia
Atrial brillation
Atrial tachycardia
Atrial utter with variable
Atrial utter
block
Inappropriate sinus tachycardia
Multifocal atrial
Sinus node re-entrant tachycardia
tachycardia
Atrioventricular re-entry
tachycardia (AVRT)
AV nodal re-entry tachycardia
(AVNRT)
Automatic junctional tachycardia
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AV Nodal Re-entry Tachycardia (AVNRT)
This is the commonest cause of palpitations in patients with structurally normal

hearts.
AVNRT is typically paroxysmal and may occur spontaneously or upon provocation
with exertion, caffeine, alcohol, beta-agonists (salbutamol) or sympathomimetics
(amphetamines).
It is more common in women than men (~ 75% of cases occurring in women) and
may occur in young and healthy patients as well as those suffering chronic heart
disease.
Patients will typically complain of the sudden onset of rapid, regular palpitations.
The patient may experience a brief fall in blood pressure causing presyncope or
occasionally syncope.
If the patient has underlying coronary artery disease the patient may experience
chest pain similar to angina (tight band around the chest radiating to left arm or left
jaw).
The patient may complain of shortness of breath, anxiety and occasionally polyuria
due to elevated atrial pressure releasing atrial natriuretic peptide.
The tachycardia typically ranges between 140-280 bpm and is regular in nature. It
may cease spontaneously (and abruptly) or continue indenitely until medical
treatment is sought.
The condition is generally well tolerated and is rarely life threatening in patients with
pre-existing heart disease.
Pathophysiology
In comparison to AVRT, which involves an anatomical re-entry circuit (Bundle of

Kent), in AVNRT there is a functional re-entry circuit within the AV node.
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Different types of re-entry loops: Functional circuit in AVNRT (left), anatomical circuit in AVRT
(right)
Functional pathways within the AV node

In AVNRT, there are two pathways within the AV node:
The slow pathway(alpha): a slowly-conducting pathway with a short refractory

period.
The fast pathway (beta): a rapidly-conducting pathway with a long refractory
period.
Mechanism of re-entry in slow-fast AVNRT (ERP = effective refractory period)
Initiation of re-entry
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During sinus rhythm, electrical impulses travel down both pathways simultaneously.
The impulse transmitted down the fast pathway enters the distal end of the slow
pathway and the two impulses cancel each other out.
However, if a premature atrial contraction (PAC)arrives while the fast pathway is
still refractory, the electrical impulse will be directed solely down the slow pathway
(1).
By the time the premature impulse reaches the end of the slow pathway, the fast
pathway is no longer refractory (2) hence the impulse is permitted to recycle
retrogradely up the fast pathway.
This creates a circus movement whereby the impulse continually cycles around the
two pathways, activating the Bundle of His anterogradely and the atria retrogradely
(3). The short cycle length is responsible for the rapid heart rate.
This is the most common type of re-entrant circuit and is termed Slow-Fast AVNRT.
Similar mechanisms exist for the other types of AVNRT.
Electrocardiographic Features
General Features of AVNRT
Regular tachycardia ~140-280 bpm.

QRS complexes usually narrow (< 120 ms) unless pre-existing bundle branch block,
accessory pathway, or rate related aberrant conduction.
ST-segment depression may be seen with or without underlying coronary artery
disease.
QRS alternans phasic variation in QRS amplitude associated with AVNRT and
AVRT, distinguished fromelectrical alternansby a normal QRS amplitude.
P waves if visible exhibit retrograde conduction with P-wave inversion in leads II, III,
aVF.
P waves may be buried in the QRS complex, visible after the QRS complex, or very
rarely visible before the QRS complex.
Subtypes of AVNRT
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Different subtypes vary in terms of the dominant pathway and the R-P interval. The RP interval represents
thetime between anterograde ventricular activation (R wave) and retrograde atrial activation (P wave).
1. Slow-Fast AVNRT (common type)
Accounts for 80-90% of AVNRT

Associated with Slow AV nodal pathway for anterograde conduction and Fast AV
nodal pathway for retrograde conduction.
The retrograde P wave is obscured in the corresponding QRSoroccurs at the end of
the QRS complex as pseudo r or S waves
ECG features:
P waves are often hidden being embedded in the QRS complexes.

Pseudo R wave may be seen in V1 or V2.
Pseudo S waves may be seen in leads II, III or aVF.
In most cases this results in a typical SVT appearance with absent P waves and
tachycardia
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Cardiac rhythm strips demonstrating (top) sinus rhythm and (bottom) paroxysmal
SVT. The P wave is seen as a pseudo-R wave (circled in bottom strip) in lead V1
during tachycardia. By contrast, the pseudo-R wave is not seen during sinus rhythm (it
is absent from circled area in top strip). This very short ventriculo-atrial time is
frequently seen in typical Slow-Fast AVNRT.
2. Fast-Slow AVNRT(Uncommon AVNRT)
Accounts for 10% of AVNRT

Associated with Fast AV nodal pathway for anterograde conduction and Slow AV
nodal pathway for retrograde conduction.
Due to the relatively long ventriculo-atrial interval, the retrograde P wave is more
likely to be visible after the corresponding QRS.
ECG features:
QRS-P-T complexes.
Retrograde P waves are visible between the QRS and T wave.
3. Slow-Slow AVNRT(Atypical AVNRT)
1-5% AVNRT
Associated with Slow AV nodal pathway for anterograde conduction and Slow left
atrial bres as the pathway for retrograde conduction.
ECG features:
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Tachycardiawith a P-wave seen in mid-diastole effectively appearing before the

QRS complex.
Confusing as a P wave appearing before the QRS complex in the face of a
tachycardia might be read as a sinus tachycardia.
Summary of AVNRT subtypes
No visible P waves? > Slow-Fast

P waves visible after the QRS complexes? > Fast-Slow
P waves visible before the QRS complexes? > Slow-Slow
Management of AVNRT
May respond to vagal maneuvers with reversion to sinus rhythm.

The mainstay of treatment is adenosine.
Other agents which may be used include calcium-channel blockers, beta-blockers
and amiodarone.
DC cardioversion is rarely required.
Catheter ablation may be considered in recurrent episodes not amenable to medical
treatment.
Other types of SVT

Most of the other types of SVT are discussed elsewhere (follow links in table above). Two less-common
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types are discussed below.

Inappropriate Sinus Tachycardia
Typically seen in young healthy female adults.

Sinus rate persistently elevated above 100 bpm in absence of physiological
stressor.
Exaggerated rate response to minimal exercise.
ECG indistinguishable from sinus tachycardia.
Sinus Node Reentrant Tachycardia (SNRT)
Caused by reentry circuit close to or within the sinus node.

Abrupt onset and termination.
P wave morphology is normal.
Rate usually 100 150 bpm.
May terminate with vagal manoeuvres.
ECG Examples
Example 1a
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Slow-Fast (Typical) AVNRT:
Narrow complex tachycardia at ~ 150 bpm.

No visible P waves.
There are pseudo R waves in V1-2.
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Pseudo R waves in V1-2
Example 1b
The same patient following resolution of the AVNRT:
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Sinus rhythm.
The pseudo R waves have now disappeared.
Pseudo R waves in V1-2 have resolved
Example 2a
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Slow-Fast AVNRT:
Narrow complex tachycardia ~ 220 bpm.

No visible P waves.
Subtle notching of the terminal QRS in V1 (= pseudo R wave).
Widespread ST depression this is a common electrocardiographic nding in
AVNRT and does not necessarily indicate myocardial ischaemia, provided the
changes resolve once the patient is in sinus rhythm.
Example 2b
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Sinus rhythm.
Pseudo R waves have disappeared.
There is residual ST depression in the inferior and lateral leads (most evident in V46), indicating that the patient did indeed have rate-related myocardial ischaemia (
NSTEMI).
Example 3
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Patient with Slow-Fast AVNRT undergoing treatment with adenosine:
The top section of the rhythm strip shows AVNRT with absent P waves and pseudo
R waves clearly visible.
The middle portion of the strip shows adenosine acting on the AV node to suppress
AV conduction there are several broad complex beats which may be aberrantlyconducted supraventricular impulses or ventricular escape beats (this is extremely
common during administration of adenosine for AVNRT).
The bottom section shows reversion to sinus rhythm; the pseudo R waves have
resolved.
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Example 4a
Fast-Slow (Uncommon) AVNRT:

Retrograde P waves are visible after each QRS complex most evident in V2-3.
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Retrograde P waves
Example 4b
Now in sinus rhythm.

The retrograde P waves have disappeared.
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Retrograde P waves resolved
Example 5a
Fast-Slow AVNRT:
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Retrograde P waves following each QRS complex upright in aVR and V1; inverted
in II, III and aVL.
Upright retrograde P waves in aVR
Inverted retrograde P waves lead II
Example 5b

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Sinus rhythm.
The retrograde P waves have disappeared.
Retrograde P waves in aVR resolved
Retrograde P waves in lead II resolved
Example 6a
Fast-Slow AVNRT:
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Narrow complex tachycardia at ~ 125 bpm.

Retrograde P waves follow each QRS complex: upright in V1-3; inverted in II, III and
aVF.
Upright retrograde P waves in V2
Inverted retrograde P waves in lead II
Example 6b
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Sinus rhythm.
Retrograde P waves have disappeared.
Retrograde P waves in V2 have resolved
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Retrograde P waves in lead II have resolved
Example 7
SVT with QRS Alternans:

Retrograde P waves are visibleprecedingeach QRS complex(upright in V1, inverted
in lead II).
There is a beat-to-beat variation in the QRS amplitude without evidence of low
voltage (= QRS alternans).
The PR interval is ~ 120 ms, so this could be either a low atrial tachycardia or
possibly an AVNRT with a long RP interval (i.e. either Fast-Slow or Slow-Slow
varieties).
Related Topics
Sinus tachycardia
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Atrial tachycardia
Atrioventricular re-entry tachycardia (AVRT)
Atrial utter
Atrial brillation
Multifocal atrial tachycardia
VT versus SVT with aberrancy
Further Reading
ECG BASICS Waves, Intervals, Segments and Clinical Interpretation

ECG CLINICAL CASES Your favourite ECGs placed in clinical context with a
challenging Q&A approach
ECG and Cardiology Eponymous Syndromes Cheats guide to eponymous
emancipation
ECG Reference Sites on the WEB the best of the rest
Author Credits
Words Mike Cadogan,John Larkin, Ed Burns

Pictures Mike Cadogan,Ed Burns
Web Editing Ed Burns
References
Surawicz B, Knilans TK. Chous Electrocardiography in Clinical Practice. 6th Edition.

Saunders Elsevier 2008.
Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine
and Acute Care. Elsevier Mosby 2005.
Brady WJ, Truwit JD. Critical Decisions in Emergency & Acute Care
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Electrocardiography. Wiley Blackwell 2009.

Jazayeri MR, Massumi A, Mihalick MJ, Hall RJ.Sinus node reentry: case report and
review of electrocardiographic and electrophysiologic features. Tex Heart Inst J.
1985 Sep;12(3):249-52. PMID: 15227012 Full Text
Fox DJ, Tischenko A, Krahn AD, Skanes AC, Gula LJ, Yee RK, Klein GJ.
Supraventricular tachycardia: diagnosis and management. Mayo Clin Proc. 2008
Dec;83(12):1400-11. PMID: 19046562 Full Text.
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About Edward Burns

Ed Burns is an Emergency Physician working in Prehospital & Retrieval
Medicine in Sydney, Australia. He has a passion for ECG interpretation and
medical education. Ed is the force behind the LITFL ECG library | + Edward
Burns | @edjamesburns
Comments
supraventricular tachycardia says

February 4, 2012 at 7:50 pm
Very well written articles on SVT. There is so much to learn from this article alone
Reply
jayakeerthi says
25/29
6/9/2016
June 28, 2012 at 10:09 pm
well done. continue the hard work. goodluck!

Reply
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HOME | ECG Library | Supraventricular Tachycardia (SVT)

Supraventricular Tachycardia (SVT)

The term supraventricular tachycardia(SVT), whilst often used synonymously with

AV nodal re-entry tachycardia (AVNRT), can be used to refer toany

SVTs can be classied based on site of origin(atria or AV node)or regularity

Classication of SVT by site of origin and regularity

Atrial utter with variable

Inappropriate sinus tachycardia

Sinus node re-entrant tachycardia

AV Nodal Re-entry Tachycardia (AVNRT)

This is the commonest cause of palpitations in patients with structurally normal

In comparison to AVRT, which involves an anatomical re-entry circuit (Bundle of

Functional pathways within the AV node

The slow pathway(alpha): a slowly-conducting pathway with a short refractory

Mechanism of re-entry in slow-fast AVNRT (ERP = effective refractory period)

Regular tachycardia ~140-280 bpm.

1. Slow-Fast AVNRT (common type)

Accounts for 80-90% of AVNRT

P waves are often hidden being embedded in the QRS complexes.

2. Fast-Slow AVNRT(Uncommon AVNRT)

Accounts for 10% of AVNRT

3. Slow-Slow AVNRT(Atypical AVNRT)

Tachycardiawith a P-wave seen in mid-diastole effectively appearing before the

Summary of AVNRT subtypes

No visible P waves? > Slow-Fast

May respond to vagal maneuvers with reversion to sinus rhythm.

Other types of SVT

types are discussed below.

Typically seen in young healthy female adults.

Sinus Node Reentrant Tachycardia (SNRT)

Caused by reentry circuit close to or within the sinus node.

Slow-Fast (Typical) AVNRT:

Narrow complex tachycardia at ~ 150 bpm.

Pseudo R waves in V1-2

The same patient following resolution of the AVNRT:

Pseudo R waves in V1-2 have resolved

Narrow complex tachycardia ~ 220 bpm.

The same patient following resolution of the AVNRT:

Patient with Slow-Fast AVNRT undergoing treatment with adenosine:

Fast-Slow (Uncommon) AVNRT:

Narrow complex tachycardia ~ 120 bpm.

The same patient following resolution of the AVNRT:

Now in sinus rhythm.

Retrograde P waves resolved

Narrow complex tachycardia ~ 135 bpm.

Upright retrograde P waves in aVR

Inverted retrograde P waves lead II

The same patient following resolution of the AVNRT:

Retrograde P waves in aVR resolved

Retrograde P waves in lead II resolved

Narrow complex tachycardia at ~ 125 bpm.

Upright retrograde P waves in V2

Inverted retrograde P waves in lead II

The same patient following resolution of the AVNRT:

Retrograde P waves in V2 have resolved

Retrograde P waves in lead II have resolved

SVT with QRS Alternans:

Narrow complex tachycardia ~ 215 bpm.

ECG BASICS Waves, Intervals, Segments and Clinical Interpretation

Words Mike Cadogan,John Larkin, Ed Burns

Surawicz B, Knilans TK. Chous Electrocardiography in Clinical Practice. 6th Edition.