Narrow complex tachycardia Dr Julian Johny Thottian DM

Narrow complex tachycardia Dr Julian Johny Thottian DM Cardiology Resident Govt. Medical College, Kozhikode

ANATOMY OF VARIOUS ACCESSORY PATHWAYS OBLIQUE VIEW OF RT ATRIUM SHOWING RE ENTRANT PATHWAY IN ATRIAL FLUTTER

ANATOMY OF KOCH`S TRIANGLE

PAC AND CONDUCTION �PAC –SINGLE/REPETITIVE OR UNIFOCAL / MULTIFOCAL IN ORIGIN �FATES OF PAC DEPENDS UPON 1) Coupling interval from the last P wave 2) Preceding cycle length or Heart rate.

BASIC UNDERSTANDING OF PAC

What`s a supraventricular tachycardia? �Heart rhythm disturbance �Initiated either in atria or ventricle �Atrial rates > 100 bpm �Requires a tissue above the His bundle to perpetuate it. NARROW COMPLEX TACHCARDIA – A TACHYCARDIA WITH QRS WIDTH <120 ms

Characteristics �Symptomatic / asymptomatic �Slow/fast �Regular or irregular �Paroxysmal , Persistent or Permanent �Generally not life threatening. �Impairs hemodynamics

Classification �AV NODE DEPENDENT 1. AVNRT 2. AVRT ANTIDROMIC ORTHODROMIC AV NODE INDEPENDENT 1. ATRIAL TACHYCARDIA 2. JUNCTIONAL ECTOPIC TACHYCARDIA 3. ATRIAL FLUTTER 4. ATRIAL FIBRILLATION

SINUS TACHYCARDIA �SYMPATHETIC ACTIVATION �GRADUAL ACCELERATION & DECELERATION �P WAVE MORPHOLOGY SIMILAR TO SINUS RHYTHM �RARELY EXCEED 200 RATE �ADENOSINE RESPONSE- SLOW AND THEN INCREASE GRADUALLY �INAPPROPRIATE- ST ABNORMAL TO SITUATION

ATRIAL FIBRILLATION Atrial activity is poorly defined & ventricular response is irregularly irregular. THEORY- Multiple wavelets, PV-automaticity, High frequency rotors, Autonomic innervation. A regular ventricular response with A-fib usually indicates high grade or complete AV block

�PAROXYSMAL- Recurrent episodes( 2 or more)that terminate within 7 days of onset �PERSISTENT- Episodes that last for more then 7 days or require cardioversion regardless of duration �LONG STANDING PERSISTENT AF- Continuous episodes of persistent AF for> 1 yr �PERMANENT – Restoration and maintenance of sinus rhythm has failed or not attempted. �An episode---Should last for 30 s - clinical AF �Fine AF- f waves <0. 5 mv , coarse AF –f waves >0. 5 mv

Ashman phenomenon- follows a long short sequence Gouaux, JL; Ashman, R (Sep 1947). "Auricular fibrillation with aberration simulating ventricular paroxysmal tachycardia. ". American heart journal 34 (3): 366– 73

ATRIAL FLUTTER �RENTRANT TACHY USUALLY FROM RT ATRIUM �ATRIAL RATE -200 -350 BPM �TYPE 1 – TERMINATED BY ATRIAL PACING, ATRIAL RATE UPTO 240 �TYPE II- CANNOT BE TERMINATED BY ATRIAL PACING ATRIAL RATE BETWEEN 240 -330/MT �MC –COUNTERCLOCKWISE- SAW TOOTHED APPEARANCE IN II, III, AVF/ NO ISO ELECTRIC SEGMENT IN BETWEEN- 90% � 10%- CLOCKWISE �ATYPICAL FORMS- LOWER/UPPER LOOP RE ENTRY/ FIGURE OF EIGHT RE ENTRY

ATRIAL TACHYCARDIA �ORIGINATE- LT, RT ATRIUMS/ VENA CAVAE/PV �FOCALTRIGGERED/MICROREENTRANT/AUTOMATIC �P OF DIFFERENT MORPHOLOGY �PR VARIES �ATRIAL RATES- 120 -200 BPM � 1: 1 CONDUCTION/AV BLOCK �ADENOSINE CAN OCCASIONALLY STOP TACHY �DIGOXIN TOXICITY- AT WITH AV BLOCK

Focal atrial tachycardia (LA focus)

Focal Atrial tachycardia �AUTOMATIC AT- GRADUAL ONSET(WARM UP)/OFFSET MAY NOT START WITH PREMATURE BEAT P WAVE DIFFERENT CONFUSION WITH ST & ASSOC ADENOSINE INSENSITIVITY TRIGGERED WITH ISOPROTERENOL & NOT WITH PROGRAMMED STIMULATION RAPID STIMULATION MAY NOT INITIATE THE TACHYCARDIA �TRIGGERED AT – SUDDEN ONSET/OFFSET ASSOC WITH RAPID PACING , DAD? ? ADENOSINE TERMINATION CATECHOLAMINE DEPENDENT PERSISTENT TACHY- CARDIOMYOPATHY �MICRO ENTRY AT- TERMINATION WITH VERAPAMIL, INITATED AND TERMINATED BY PACING

Intra Atrial re entrant tachycardia �MACRO/MICRO REENTRY- SCAR INCISIONS LIKE FONTAN �DISCRETE P WAVES AND ISO ELECTRIC BASELINE �ADENOSINE MAY TERMINATE-15% CASES

SANRT �MICROREENTRANT TACHYCARDIA �P WAVE MORPHOLOGY SIMILAR �USUALLY PRECIPITATED AND TERMINATED BY PREMATURE ATRIAL COMPLEXES. �ATRIAL RATE IS USUALLY 120 -150 BPM. �STOPS AND STARTS ABRUPTLY �AV BLOCK CAN OCCUR.

MULTIFOCAL ATRIAL TACHYCARDIA �ALSO KNOWN AS CHAOTIC ATRIAL TACHYCARDIA �ACTIVATION FROM MULTIPLE PLACES �ATLEAST 3 DIFFERENT P WAVE MORPHOLOGIES �ISOELECTRIC BASELINE BETWEEN P WAVES �ATRIAL RATE -110 -170 BPM �COPD, ELDERLY , SEPSIS, HT �EXACERBATED BY THEOPHYLLINE

Multifocal Atrial Tachycardia

AV NODAL REENTRANT TACHYCARDIA

AVNRT �PRESENCE OF 2 PHYSIOLOGICAL/ANATOMICAL AV NODAL PATHWAYS � 65% OF REGULAR SVT �ACTIVATION- VIA SLOW FIRST THEN FAST �RATES 150 -200 BPM �BEGINS WITH PREMATURE ATRIAL DEPOLARISATION �PSEUDO R`- V 1, PSEUDO S-II III AVF �W>M MORE IN ADULTS �STOPS WITH VAGAL MANEUVRES ABRUPTLY

AVNRT �NO P waves �P waves are retrograde and are inverted in leads II, III, AVF. �P waves are buried in the QRS complexes –simultaneous activation of atria and ventricles – most common presentation of AVNRT – 66%. �If not synchronous –pseudo s wave in inferior leads , pseudo r’ wave in lead V 1 ---30% cases. �P wave may be farther away from QRS complex distorting the ST segment ---AVNRT , mostly AVRT.

AFTER ADENOSINE

AVRT �Typical – RP interval < PR interval �RP interval > 80 milli sec �Atypical –RP interval > PR interval �Concealed bypass tract – only retrograde conduction �Manifest bypass tract– both anterograde and retrograde. �Electrical alternans –the amplitude of QRS complexes varies by 5 mm alternatively. �Rate related BBB occuring and the rate of tachycardia is decreasing –then the bypass tract is on the same side of the block.

AV REENTRANT TACHYCARDIA

PR interval PRinterval RP interval

AVRT �MACRO RE ENTRANT CIRCUIT �TYPICAL- ANTEGRADE –AV NODE RETROGRADE VIA ACCESSORY PATHWAY- ORTHODROMIC -30% REGULAR SVT �QRS ALTERNANS �CAN BE CONCEALED/MANIFEST �DELTA WAVE �STOPS WITH VAGAL MANEUVRES ABRUPTLY

PRE EXCITATION SYNDROMES �WPW PATTERN-MANIFEST ANTEGRADE CONDUCTION THROUGH AP-PRE EXCITE THE VENTRICLE-WPW PATTERN �ASSOC WITH PALPITATIONS –WPW SYNDROME �ORTHODROMIC SVT IS THE MOST COMMON �IN 10% ANTEGRADE CONDUCTION VIA AP

WPW syndrome �Two types �Orthodromic �Antidromic is wide complex tachycardia �In NSR detected by delta wave. �Can ppt AF and VF on use of AV nodal blockers �MEMBRANE ACTIVE ANTIARRHTYHMIC DRUGS are safe. �CONCEALED WPW syndrome – no delta wave. less risk of AF

Orthodromic AVRT

OTHER PRE EXCITATIONS �MAHAIM- ATRIOFASCICULAR PATHWAY CONNECTS ATRIUM TO RT BUNDLE BYPASSING AV NODE �DECREMENTAL PROPERTIES �SHORT PR WITH NO MANIFEST PRE EXCITATION �LAD & LBBB- RA TO RT BUNDLE �MAHAIM CONDUCT IN ANTEROGRADE DIRECTION ONLY

PERMANENT JUNCTIONAL RECIPROCATING TACHYCARDIA �PJRT- PERSISTENT AVRT CONDUCTION VIA AV NODE>> POSTEROSEPTAL SLOW AP �LONG RP TACHCARDIA �P FAR AFTER QRS

PJRT

JUNCTIONAL ECTOPIC TACHYCARDIA �AUTOMATIC / TRIGGERED �ORIGINATES AROUND AV NODE �PERSISTENT RHYTHM �DOESNOT GENERALLY TERMINATE WITH ADENOSINE �CHILDREN POST CARDIAC SX, AMI, CARDIOVERSION OF AF, MYOCARDITIS , DIGOXIN TOXICITY �SVT WITH AV DISSOCIATION

DIAGNOSIS �ABRUPT RAPID PALPITATIONS �DIZZINESS �SYNCOPE WITH VERY FAST RATE �DYSPNOEA �CHEST DISCOMFORT �RELIEF WITH VAGAL MANEUVRES �CANNON WAVES- TYPICAL AVNRT �IRREGULAR PULSE , PULSE DEFICIT> 10 IN AF

ECG findings

2. MODE OF INITIATION

MODE OF INITIATION

MODE OF INITIATION

MODE OF INITITIATION-AVRT

1. Spontaneous change in cycle length 2. No definite PR jump 3. Change in P wave morphology

3. MODE OF TERMINATION

4. MORPHOLOGY OF P WAVES �P waves in lead Avl- Positive or biphasic (negativepositive) -Right Atrial Focus (Right to left activation) �P waves in lead a. VL- Negative or isoelectric: Left atrial focus �P waves in V 1– Positive (Posterior to anterior/ left-to-right activation): Left atrial focus Negative or biphasic (anterior to posterior/ right-to-left activation): Right atrial focus �P waves in inferior leads– Positive (High to low activation): HRA/ High LA Negative (Low to high activation): Retrograde P in AVNRT, AVRT or AT with low atrial focus (e. g. CS/ low CT)

P wave morphology contd… Counter clockwise Typical A Flutter: Positive P waves in II/III/a. VF, Biphasic F wave in I, a. VL, V 1 Upright F wave in V 6 Clockwise Flutter waves –ve in inferior leads & V 6 & +ve in V 1

5. MORPHOLOGY OF QRS

6. VARIATION IN CYCLE LENGTH

7. RESPONSE TO VALSALVA & AV BLOCKER

7. EFFECT OF BBB & AVB

NCT DIAGNOSTIC FEATURES AV RATIO>1 (A>V)-AT, AFL, AVNRT(rare) A=V- AVNRT, AVRT, AT, JT <1(A<V)- AVNRT, JT , NODOFASCIULAR TACHYCARDIA Cardiac electrophysiology, Zipes 6 th edition

THANK YOU

REFERENCES

TEXT BOOKS �CARDIAC ELECTROPHYSIOLOGY- ZIPES 6 TH EDITION �HURST`S-THE HEART -13 TH EDITION FUSTER, WALSH, HUNT, PRYSTOWSKY �BRAUNWALD`S HEART DISEASE-9 TH EDITIONBONOW, MANN, ZIPES �AN ILLUSTRATED TEXT BOOK ON HEART DISEASE BY KANU CHATTERJEE �ECG TEXT BOOK –CHOU �PEARLS AND PITFALLS - MARRIOT

QUESTION 1 �TYPICAL LONG RP TACHYCARDIA IS NOT SEEN IN 1. PJRT 2. AVRT 3. AVNRT TYPICAL 4. AVNRT ATYPICAL

QUESTION 2 �QRS ALTERNANS IS NOT SEEN IN 1. AVRT WITH MULTIPLE ACCESSORY PATHWAYS 2. ATRIAL FLUTTER 3. AVNRT WITH MULTIPLE FAST AND SLOW PATHWAYS 4. AVRT WITH DUAL AV NODAL PHYSIOLOGY

QUESTION 3 �FALSE ABOUT MAT 1. ATRIAL RATE 110 -170 2. PRECIPITATED BY THEOPHYLLINE 3. ISOELECTRIC BASELINE BETWEEN P WAVES 4. CINSECUTIVE THREE DIFFERENT P WAVE MORPHOLOGY

QUESTION 4 �FALSE IS 1. IN RIGHT ATRIAL FOCUS – LEAD AVL POSITIVE P WAVE 2. IN LEFT ATRIAL FOCUS – LEAD AVL NEGATIVE P WAVE 3. IF P IN II III AVF POSITIVE – FOCUS HRA 4. IF P IN VI POSITIVE- RT ATIAL FOCUS

QUESTION 5 �PR=RP IS NOT SEEN IN 1. ATRIAL FLUTTER WITH 2: 1 BLOCK 2. FOCAL ATRIA TACHYCARDIA 3. JUNCTIONAL TACHYCARDIA 4. TYPICAL AVNRT

QUESTION 6 �GRADUAL ONSET OR`WARMING UP` IS NOT SEEN IN 1. AVRT 2. AVNRT 3. AT 4. JUNCTIONAL TACHYCARDIA

QUESTION 7 �FALSE ABOUT MAHAIM TACHYCARDIA 1. PATHWAY HAS DECREMENTAL PROPERTIES 2. CONDUCTS BOTH ANTEROGRADE & RETROGRADE DIRECTIONS 3. ATRIO HISIAN PATHWAY 4. LBBB MORPHOLOGY FOR TACHYCARDIA

QUESTION 8 � FALSE ABOUT AVNRT 1. PSEUDO S- 30% 2. PSEUDO Q- 4% 3. P AFTER QRS IS VERY COMMON 4. NO PWAVES IS SEEN IN 66% CASES

QUESTION 9 �IRREGULAR R-R INTERVAL IS SEEN IN ALL EXCEPT 1. AF 2. AFL WITH VARIABLE BLOCK 3. MAT 4. SNRT

QUESTION 10 �FALSE ABOUT `ASHMAN PHENOMENON` 1. SEEN COMMONLY IN ATRIAL FIBRILLATION 2. RBBB MORPHOLOGY OF CONDUCTED BEAT 3. SEEN IN SHORT LONG SEQUENCE 4. DURATION OF THE REFRACTORY PERIOD OF THE MYOCARDIUM IS PROPORTIONAL TO THE R-R INTERVAL OF THE PRECEDING CYCLE