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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Commonly observed in children

  • Heart rate may vary from 120 to 250 bpm

  • Tachycardia cardiomyopathy may occur because the tachycardia tends to be incessant

  • This is a reentrant tachycardia and quite sensitive to autonomic manipulation

  • Tachycardia tends to slow down with age because retrograde conduction through the accessory pathway tends to slow down

GENERAL CONSIDERATIONS

  • This is reentrant arrhythmia induced by a retrogradely conducting (concealed) decremental accessory pathway

  • It may occur in the perioperative period in infants and children

  • The perioperative form is self-limiting; however, heart rates > 200 bpm may cause marked hypotension

  • The idiopathic form can persist for years, leading to tachycardia cardiomyopathy

  • P waves precede the QRS complexes (long RP tachycardia)

  • The P waves are inverted in inferior leads

  • The pathway causing this type of orthodromic reciprocating tachycardia is commonly located at or near the os of the coronary sinus

  • Drug therapy does not control this arrhythmia secondary to prolonged conduction property of the accessory pathway, although rate control can be achieved

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Palpitations

  • Shortness of breath

  • Features of congestive heart failure

PHYSICAL EXAM FINDINGS

  • Elevated jugular venous distention

  • S3 may be heard during sinus rhythm

  • Bilateral pulmonary rales

DIFFERENTIAL DIAGNOSIS

  • Automatic atrial tachycardia

  • Atypical atrioventricular nodal reentrant tachycardia

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • CBC, basic metabolic panel

ELECTROCARDIOGRAPHY

  • ECG shows a narrow QRS with inverted P waves in the inferior leads

  • Outpatient cardiac monitor is used to detect and document rhythm disturbance

IMAGING STUDIES

  • Echocardiogram to evaluate left ventricular function

DIAGNOSTIC PROCEDURES

  • Electrophysiologic study to define mechanism of rhythm disturbance and determine suitability for ablation

TREATMENT

CARDIOLOGY REFERRAL

  • Patients suspected to have this disorder should be referred to an electrophysiologist

HOSPITALIZATION CRITERIA

  • Patients in active heart failure

  • After ablation for 24 hours

MEDICATIONS

  • Drug therapy is frequently not helpful

  • Class IC drug or amiodarone may achieve rate control

  • Digoxin has no effect, and verapamil may accelerate the tachycardia

  • Beta blockers may control heart rate in adults

THERAPEUTIC PROCEDURES

  • Radiofrequency ablation is successful in 95% of patients

SURGERY

  • Not required

MONITORING

  • ECG monitoring in the hospital

DIET AND ACTIVITY

  • General healthy lifestyle

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA

  • Adequate treatment of ...

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