Supraventricular

tachyarrhythmias (SVT)

Asist. Univ. Dr. Mihaela Popescu

Catedra de Cardiologie Spitalul Universitar
de Urgenta Elias
What is this???
First step dont panic !

Tachycardi
a

Narrow Wide
complex complex

Regular Irregular Regular Irregular

Defining terms
Antegrade conduction from the atria to the
ventricles
Retrograde conduction from the ventricles

to the atria

Ortodromic antegrade conduction through

the AV node, retrograde conduction through the
accesory pathway
Antidromic - antegrade conduction through

the accesory pathway, retrograde conduction

through the AV node
Wide complex SVT
SVT is associated with wide QRS complex
only when:

1. Preexistent bundle branch block

2. Accesory pathway antegrade conduction
3. Abberant conduction
 Narrow Wide QRS- bundle block/
QRS abberant conduction

QRS morphology
based on origin and
conduction

Wide QRS-preexcitation- Wide QRS- VT

1. Narrow QRS complex
tachycardia conduction via accesory pathway
2. Wide QRS complex
tachycardia
QRS Width: Synchronous vs. Asynchronous
Ventricular Activation
QRS
Normal synchronous
overlapping activation Narrow
of both ventricles:

On
time Late
Asynchronous Wide
scenario I:

On
Head start time
(or late) Wide
Asynchronous
scenario II:
A. Re- entry SVT types and
1. SN reentrant mechanisms 1
3 4
tachycardia
2. Atrial reentrant
tachycardia (atrial
flutter)
3. AV node reentrant
tachycardia- slow/fast
pathway
4. AV reentrant 2

tachycardia-accesory
pathway
B. Automatism
1. Atrial automatic
2. Jonctional automatic
Regular SVT
Sinus tachycardia
Atrial flutter
Atrial tachycardia
AV node reentrant
tachycardia
AV reentrant
tachycardia
Irregular SVT

Atrial Fibrillation
Multifocal atrial tachycardia (TAM)
Atrial Flutterul with variable
conduction block
Diagnostic protocol

Atrialactivity
QRS morphology
R-R interval
Abberant conduction
Response to vagal maneuvers
Atrial premature beats

Mechanism: abnormal automatism

morphology
Early p wave, before the QRS
P wave morphology sinus p wave morphology
Noncompensatory pause, delays the cardiac
rhythm
Narrow QRS <120ms
Possible nonconducted p wave after the
premature beat
Treatment: only if symptomatic or very frequent risk
of atrial Fibrillation
Beta blockers, calcium channel-blockers.
 Ventricular premature
beats
mechanism: abnormal automatism
morphology:
No p wave
Compensatory pause, does not
delay the cardiac rhythm
Wide QRS >120ms
Sinus tachycardia

Frequency>100 b/min
p wave of constant morphology
Causes:
Hyperthyroidism
Hypovolemia
Hypotension
Fever
Respiratory failure
Pain
Ischemic disease
Respiratory sinus
arrhythmia

Normal morphology p wave

Variation of sinus frequency
Normal in the young through vagal hypertonia
P-P gets short in deep breathing, through decreased vagal
tone
Dissappears with effort or through simpatic stimulation
Multifocal atrial tachycardia
(MAT)

Mechanism:abnormal automatism
Frequency: 100-140/min
Different p wave morphologies in the same lead
Narrow QRS
Irregular rhythm, variable PR interval
Can degenerate into atrial fibrillation
Treatment: beta blockers, amiodarone,
verapamil
Jonctional tachycardia

mechanism: abnormal automatism

regular tachycardia with narrow QRS, 70-130/min

variabil/ absent P; (negativ DII, DIII, aVF, before or after QRS)

Etiology:
Digitalis intoxication

congenital

Miocarditis, carditis in acute rheumatic fever

Inferior MI

mitral valve surgery

Treatment: according to cause

 re-entry mechanism

bidirectional Unidirectional Recovery of

conduction Block excitability
and reentry
AV node reentrant tachycardia
(AVNRT)
 AV node reentrant tachycardia
(AVNRT)
F = fast pathway

S = slow pathway
(His
Bundle)

During sinus rhythm,

the impulse is
conducted preferentially
on the fast pathway
AV node reentrant tachycardia
(AVNRT)
Frequency= 150-250
b/min

retrograde P
waves (AVN
atria) appear
within or at the
end of the QRS
AV node reentrant tachycardia
(AVNRT)
AV node reentrant tachycardia
(AVNRT)
Retrograde p wave
Negative in DII, DIII, aVF
Positive in V1
Pseudo S in DII
Pseudo R in V1
AV node reentrant tachycardia
(AVNRT)
AV node reentrant tachycardia
(AVNRT)
AV node reentrant tachycardia
(AVNRT)
AV node reentrant tachycardia
(AVNRT)
Treatment

Acute:

EES if there is hemodynamic deterioration

Adenozine 6-12 mg IV

Verapamil 5-10 mg IV

Metoprolol 5 mg iv

Chronic, prophilactic:
Paleative
Beta blockers

Calcium channel blockers

Curative
Electrophisiologic study and abblation of the slow pathway
Preexcitation syndrome
Accesory conduction pathway between atria and ventricles:
embrionic myocardial tissue
Not always manifest= doesnt always conduct

Very fast conduction

atrio-Ventricular or ventriculo-atrial conduction

When the impulse is conducted via the accesory pathway, the

QRS complex is the result of the fusion between the

depolarization through the AVN and through the accesory

pathway
ECG:

Short PR < 0.12 sec

delta wave

Wide QRS > 0.12 sec

Negative T wave

Pre-excitation + reentrant tachyarrhythmias= WPW

syndrome
Preexcitation syndrome

Sinus impulse
Hybrid QRS
Delta wave
PR < .12 s
AP

Ventricular activation QRS .12 s

through fusion
Preexcitation syndrome
Preexcitation syndrome = antegrade conduction
through the AP in sinus rhythm
Constant- permanent delta wave (sometimes variable
accordion effect)

Intermitent conduction (intermitent delta)

Apparently absent

associated tachyarrhythmias = WPW SYNDROME

Ortodromic atrioventricular reentry
NB!: (sometimes ,,hidden AP only retrograde conduction V-A)

antidromic atrioventricular reentry

,,preexcitated AF
Preexcitation syndrome
Preexcitation syndrome
Variable duration delta wave,
accordion effect
Varying Degrees of Ventricular Preexcitation-
Variable duration delta wave, accordion effect
Preexcitation syndrome
intermitent Delta
wave
AV reentrant tachycardia (AVRT)
ortodromic

mechanism:

antegrade conduction through the AV node

Retrograde hidden conduction
Narrow QRS
Preexcitation is not apparent

Frequency180-200 / min
Regular narrow QRS complex tachiarrhythmia
Second cause of sustained SVT
AV reentrant tachycardia (AVRT)
ortodromic

Anterograde
conduction on
normal pathways
Retrograde
conduction pn
accesory
pathway
AV reentrant tachycardia (AVRT)
ortodromic
APB
Initiation of AVRT
Atria

AP

AVN APB

Ventricles

APB = atrial premature beat

AV reentrant tachycardia (AVRT)
ortodromic
maintaining
AVRT
Atria
Frequency=150-250 b/mi

AP

AVN

Ventricles
retrograde P on the ST
AV reentrant tachycardia (AVRT) ortodromic
AV reentrant tachycardia (AVRT)
antidromic
AV reentrant tachycardia (AVRT)
antidromic
mechanism:
Antegrade conduction on AP
Retrograde conduction through AVN

Regular wide QRS tachycardia because of the delta

Fast ventricular response > 180-200/min
differential dg with sustained monomorphic VT
High risk of sudden cardaic death in case of AF- VF
AV reentrant tachycardia (AVRT)
antidromic
Sdr WPW cu Fibrillation
atrial
Treatment for WPW
syndrome
Preexcitation without tachyarrhythmias (delta wave SR): surveillance
WPW Sdr (preexcitation with tachyarrhythmias)
Acute (conversion to SR):

EES if there is hemodinamic instability (!! AF with pre-ex.)

ortodromic,narrow QRS :
Adenozine iv

antidromic, wide QRS

class Ia, Ic, III
Prophilactic, chronic:

class Ia, Ic, III

ABLATION of the accesory pathway

CONTRAINDICATION:
Digoxin
Calcium channel blockers
Atrial Flutter
Not so frequent as AF
AFl paroxysmal can appear on a normal
heart
Chronic AFl = pathological heart
Causes = same as for AF
Miocarditis, ARF, hyperthyroidism

Ischemic heart disease, cardiomyopathy

Alcoolism, pericarditis

Mi, Tri valve disease

Pulmonary embolism

Post cardiac surgery

Aritmie recurenta
Atrial Flutter
mechanism: macroreentry circuit
Regular narrow QRS tachycardia
Absent P waves, F waves 250-350 / min, izoelectric

line:
FlA -tipical (antiorar): negative in DII, DIII, aVF

FlA -inversed tipical (orar): positive in DII, DIII, aVF

FlA -atipical: >350 / min, variable morphology

Untreated : conduction AV 2/1 (~ 150 / min)

Possible variable conduction : 2/1, 4/1, 3/1
Vagal maneuvers lower the HR, dont stop the flutter
Atrial Flutter
Atrial Flutter

Dupa CSC
Atrial Flutter
Treatment
Acute
cardioversion (low energy EES)
clasa I iv
CCB iv
B iv
Vagal maneuvers
Chronic
Rhythm control

curativ?
NB!: risk of embolism
Same anticoagulation guidelines as for AF
Atrial fibrillation
Atrial
Fibrillation
Multiple focal
depolarization
s

rapid atrial
frequency 400-600
b/min
Atrial Fibrillation
V5

V1

The majoritaty of the impulses are blocked

in AVN
The differential
diagnosis of narrow
complex
tachycardia
ECG analysis: the RP
interval
Useful in distinguishing AV reentry
from AV node reentry tachycardias
70 msec - traditionally associated
with AVNRT

> 70 msec-accessory pathway

> PR interval -PJRT or atypical AVNRT

Tachycardia Induced
Cardiomyopathy
Chronic tachycardia in otherwise
structurally normal heart as the sole
cause of developing ventricular
dysfunction
Can follow any chronic cardiac

tachyarrhythmia

Fenelon G et al. Pacing Clinical Electrophysiol 1996;19:95

Conditions predisposing to, or
encouraging progression of AF
Types of atrial fibrillation
Initial clinical evaluation
 Natural time course of AF

AF = atrial fibrillation
Management of AF patients

ACEI = angiotensin-converting enzyme inhibitor; AF = atrial fibrillation; ARB = angiotensin receptor blocker;
PUFA = polyunsaturated fatty acid; TE = thrombo-embolism.
 CHADS2 Score
CHADS2 score Risk
Criteria
C Congestive heart failure 1
H Hypertension high blood 1
pressure
A Age75 1
D Diabetes mellitus 1
S2 Stroke or TIA (transient 2
ischemic attack)

CHADS2 score is applied only for the non-valvulara AF

Valvulara atrial fibrillation is associated with
rheumatic valve disease,
Mechanic valves
hypertrophic cardiomyopathy
 Scorul CHA2DS2-VASc

*Prior myocardial infarction,

peripheral artery disease, aortic
plaque. Actual rates of stroke in
contemporary cohorts may vary
from these estimates.
 Thromboprophilaxis in AF

AF = atrial fibrillation; CHA2DS2-VASc = cardiac failure, hypertension, age 75 (doubled), diabetes, stroke
(doubled)-vascular disease, age 6574 and sex category (female); INR = international normalized ratio;
OAC = oral anticoagulation, such as a vitamin K antagonist (VKA) adjusted to an intensity range of INR
2.03.0 (target 2.5).
 HAS-BLED bleeding score

*Hypertension is defined as systolic blood pressure > 160 mmHg.

INR = international normalized ratio.
 Cardioversion, TOE and anticoagulation

AF
AF =
= atrial
atrial fibrillation;
fibrillation; DCC
DCC =
= direct
direct current
current cardioversion; LA = left atrium; LAA = left atrial appendage; OAC = oral anticoagulant;
SR=
SR= sinus rhythm; TOE= transoesophageal echocardiography.
sinus rhythm; TOE= transoesophageal echocardiography.
 Pharmacological conversion of recent
onset AF

ACS = acute coronary syndrome; AF = atrial fibrillation; DCC = direct current cardioversion; i.v. = intravenous;
N/A = not applicable; NYHA, New York Heart Association; p.o. = per os; QRS = QRS duration; QT = QT interval;
T-U = abnormal repolarization (T-U) waves.
 Pharmacological an electrical
conversion of recent onset AF

AF = atrial fibrillation; i.v. = intravenous.

General Management of the AF Patient
 Rate
Control

ER = extended release formulations; N/A =

not applicable. Only in patients with non-
permanent atrial fibrillation.
ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; CAD = coronary artery disease; CHF =
congestive heart failure;
HT = hypertension; LVH = left ventricular hypertrophy; NYHA = New York Heart Association; unstable = cardiac
decompensation within the prior
4 weeks. Antiarrhythmic agents are listed in alphabetical order within each treatment box. ? = evidence for upstream
therapy for prevention of atrial
remodelling still remains controversial.