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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Atrial rate of 120–240 bpm

  • P waves different from sinus P wave

  • Structural heart disease in most cases

GENERAL CONSIDERATIONS

  • Occurs with supraventricular tachycardia in 6% of the population

  • P-wave morphology is different from sinus P-wave morphology and differentiates it from sinus node reentry and inappropriate sinus tachycardia

  • May present in the adult following prior atrial surgery for congenital heart disease

  • Occurs in paroxysms that are frequently sustained, responding to vagal maneuvers only 25% of the time

  • Precipitated by closely coupled atrial depolarization and does not exhibit warm-up phase

  • The substrate that facilitates reentry is inhomogeneity of atrial conduction, refractoriness, or both

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Palpitations

  • Dyspnea

PHYSICAL EXAM FINDINGS

  • Usually findings of underlying structural heart disease

  • Many patients have features of heart failure such as S3, elevated jugular venous distention, and rales in the lung fields

DIFFERENTIAL DIAGNOSIS

  • Automatic atrial tachycardia

  • Atypical atrioventricular (AV) nodal reentrant tachycardia

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • CBC, basic metabolic panel

ELECTROCARDIOGRAPHY

  • ECG: may document rhythm disturbance or point to underlying heart disease

  • Outpatient cardiac monitoring to detect rhythm disturbance

IMAGING STUDIES

  • Echocardiogram to evaluate structural heart disease

DIAGNOSTIC PROCEDURES

  • Invasive electrophysiologic study to assess rhythm mechanism

TREATMENT

CARDIOLOGY REFERRAL

  • All patients should be evaluated by a cardiac electrophysiologist

HOSPITALIZATION CRITERIA

  • If the patient has active heart failure or is hemodynamically unstable

MEDICATIONS

  • Beta blockers or calcium channel blockers with negative chronotropic properties (verapamil or diltiazem)

  • Amiodarone, class IC, and other class III drugs are alternatives when the arrhythmia is difficult to control

THERAPEUTIC PROCEDURES

  • Radiofrequency ablation of the slow conduction area that facilitates macroreentry is associated with high success rate

  • AV nodal ablation followed by permanent pacemaker implantation is a last resort if the arrhythmia cannot be ablated (very rare)

SURGERY

  • Generally not required

MONITORING

  • ECG monitoring in hospital

DIET AND ACTIVITY

  • Depends on underlying cause

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA

  • After radiofrequency ablation or adequate rate control on medications

FOLLOW-UP

  • Two weeks after discharge from hospital; thereafter, depends on clinical situation

COMPLICATIONS

  • Uncontrolled tachycardia may worsen cardiomyopathy

  • Atrial fibrillation is common ...

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