Narrow Complex Tachycardia
Dr. Samiha Sultana
MBBS,D-Card (course)
Shaheed Ziaur Rahman Medical College & Hospital
What is narrow complex tachycardia?
When ECG shows heart rate >100 bpm with QRS complex
duration <120ms,then it is called narrow complex tachycardia.
Tachycardia may be :
Supraventricular or Ventricular.
When tachycardia originates above the
bifurcation of Bundle of his- usually in the
atria/Atrioventricular (AV) junction,then it
is supraventricular.
Supraventricular impulse follow the
normal AV conduction system activate
both ventricles synchronously resulting in
narrow QRS complex measuring < 120
millisecond.
Sinus tachycardia
Sinus tachycardia refers to impulses that originate from the sinus
node with a rate that exceeds 100 bpm.
Cause-
1. Physiologic – exercise, emotion,fear/anxiety.
2.Pathologic –
a. Acute pulmonary embolism.
b. Acute pulmonary edema
c. Thyrotoxicosis
d. Infection
e. Anaemia
f. Hypotension,shock/haemorrhage
3. Drugs- Atropine,hydralazine, Epinephrine or Norepinephrine
Atrial Fibrilation
• Irregular Narrow Complex tachycardia.
• The commonest sustained arrythmia.
• Atrial activity appears as irregular baseline or f (fibrillatory) waves.
• Irregular ventricular rate.
ECG features of Atrial fibrillation-
1. Irregularly irregular rhythm.
2. No P waves.
3. Unstable baseline – may have fine or coarse “fibrillatory
waves”
4. Narrow QRS complex (unless other conduction pathology)
Classification of Atrial fibrillation:
According to duration:
a)First-detected – initial detection of AF regardless of
symptomps/duration.
b)Recurrent AF – more than 2 episode of AF.
c)Paroxymal AF – self terminating episode < 7 days.
d)Persistant AF- Not self terminating duration >7 days.
e)Long standing persistent AF >1 year.
f)Permanent AF – Duration >1 year in which rhythm control
interventions are unsuccessful.
Cause of Atrial Fibrillation:
1. Mitral Valvular heart disease ( commonly MS)
2. Ischaemic heart disease (Commonly after MI)
3. Thyrotoxicoxis
4. Lone atrial fibrillation.
5. Hypertension
6. Others-
-ASD
-Chronic constrictive pericarditis,Acute pericarditis
-Crdiomyopathy
-Myocarditis
-SIX sinus syndrome
-Coronary bypass surgery
-Cor pulmonale
-Severe pneumonia
-Alcohol,
-Lung disorder – Pulmonary embolism,COPD.
Management
According to ESC guideline optimal treatment of AF-CARE
pathway includes:
CARE
C- comorbidity & risk factors management.
A- avoid stroke & thromboembolism.
R- reduce symptomps by rate & rhythm control.
E- evaluation & dynamic reassessment.
Atrial Flutter
• Atrial rate usually ~300/min
• Associated with 2:3, 3:1, 4:1 AV block.
• No baseline in II , III, aVF.
• Same causes as atrial fibrillation.
ECG features-
• Flutter waves- “Saw tooth pattern” best seen in II,III & aVF .
• May resemble P wave in v1.
Management
• Similar to atrial fibrillation.
- Requires anticoagulation
• More Difficult to control rate with medical treatment
compared to atrial fibrillation
• Usually requires DC Cardioversion
• Radiofrequency ablation highly successful in restoration and
maintenance of sinus rhythm
Supraventricular Tachycardia (SVT)
• It refers to any tachycardia originating in the atria or AV node.
ECG features:
• Narrow complex tachycardia.
• P-wave usually absent (P-wave buried within QRS complex)
Causes of SVT-
• Aberrant conduction pathway
• IHD
• Ebstein anomaly
Provoking factor – Tobacco,Tea, Coffee,Alcohol.
Management
*Acute Episode
For hemodynamically stable patient.
-Vagal Maneuvers
-Valsalva, modified Valsalva,carotid sinus massage
-IV adenosine.
-DC Cardioversion in hemodynamically unstable patient.
*Prevention
-Life style modification
-PO Beta blockers, Calcium Channel Blockers.
-Radiofrequency Ablation
Atrioventricular Nodal Reentrant Tachycardia (AVNRT)
• Regular Narrow Complex Tachycardia.
• Usual rate 150–250.
• Abrupt onset and offset.
• Variable relation to P wave:
– P wave buried in the QRS
– Short RP interval
–Usually no underlying heart disease
Mechanism of AVNRT
Atrioventricular Reentrant Tachycardia (AVRT)
• AVRT is a form of paroxysmal supraventricular tachycardia.
• Occurs in patients with accessory pathways, usually due to
formation of a re-entry circuit between the AV node and
accessory pathway.
• ECG features depend on the direction of conduction, which
can be orthodromic or antidromic.
Orthodromic AVRT: Anterograde conduction through AV node
Antidromic AVRT: Retrograde conduction through AV node
• In orthodromic AVRT, anterograde conduction is via the AV node, producing a
regular narrow complex rhythm (in the absence of pre-existing
bundle branch block),it is associated with in Wolff-Parkinson-White(WPW)
syndrome.
Orthodromic AVRT: Regular, narrow complex tachycardia
Atrial tachycardia
ECG Features:
• P wave: small abnormal shape (may be upright or inverted)
• Atrial rate. 140 to 220/minute.
• QRS: normal.
• Rhythm: normal
• There may be 2:1,3:1 or variable AV block
Atrial tachycardia
Management
•AV nodal blocking agents.
•Some are amenable to Radiofrequency ablation
Multifocal Atrial Tachycardia (MAT)
• Irregular Narrow Complex Tachycardia.
• At least three distinct P-wave morphologies in the same
ECG lead
• Varying PP, PR, RR intervals
Causes:
• COPD
• Cor pulmonale
• Hypoxia
• Heart Failure
• Postoperative state
• Sepsis
• Pulmonary edema.
Multifocal atrial tachycardia:
• Rapid irregular rhythm > 100 bpm.
• At least 3 distinctive P-wave morphologies (arrows).
Management
• Treatment of the underlying cause.
• Correction of electrolytes (K, Mg).
• AV nodal blocking agents.
• Anticoagulation depending on stroke risk.
Junctional tachycardia
AV junctional tachycardia is due to repetitive impulses originating from the
AV node or bundle of His.The impulse follows the normal Av conduction
system resulting in narrow QRS complexes.
• AV junctions intrinsic rate is 40-60 bpm
• Accelerated Junctional Rhythm: 60-100 bpm .
• Junctional Tachycardia: > 100 bpm
Junctional Tachycardia
-Narrow complex tachycardia at 115 bpm.
-Retrograde P waves - inverted in I1, Ill and aVF; upright in V1 and aVR.
-Short PR interval (< 120 ms) indicates a junctional rather than atrial focus
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