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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Heart rates > 100 bpm at rest or with minimal exertion

  • Mean heart rate > 90 bpm over 24 hours

  • P waves identical or nearly identical to sinus P wave

  • Chronic duration of symptoms

  • Exclusion of other causes of sinus tachycardia

GENERAL CONSIDERATIONS

  • Frequently seen in young female health care workers

  • May occur transiently after ablation of other supraventricular arrhythmias

  • The arrhythmia is nonparoxysmal and not associated with an underlying cardiac pathologic process

  • Alteration in autonomic tone with increase in sympathetic output or reduction in parasympathetic tone is likely to be the primary abnormality

  • Primary problem of the sinus node itself and beta-adrenergic hypersensitivity suggested in some studies

  • May cause tachycardia cardiomyopathy if untreated

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Chest pain

  • Palpitations

  • Dyspnea

  • Near syncope

PHYSICAL EXAM FINDINGS

  • Tachycardia

DIFFERENTIAL DIAGNOSIS

  • Appropriate sinus tachycardia

  • Sinus node reentry

  • Atrial tachycardia

  • Postural orthostatic tachycardia syndrome (POTS)

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Serum thyroid-stimulating hormone

  • CBC, basic metabolic panel

ELECTROCARDIOGRAPHY

  • ECG to document rhythm disorder

IMAGING STUDIES

  • Echocardiogram if there are features of heart failure

DIAGNOSTIC PROCEDURES

  • Electrophysiologic study may be necessary to establish mechanism of arrhythmia and determine suitability for ablation

TREATMENT

CARDIOLOGY REFERRAL

  • Electrophysiology referral is required if heart rate cannot be controlled with adequate doses of beta blockers

HOSPITALIZATION CRITERIA

  • Usually not required except in tachycardia cardiomyopathy

MEDICATIONS

  • High doses of beta blockers (atenolol 100–200 mg/day) or propranolol 320 mg/day

  • Rate-lowering calcium channel blockers

THERAPEUTIC PROCEDURES

  • Radiofrequency modification of sinoatrial node (high recurrence rate of 20–30%)

  • Intracoronary ethanol ablation may be tried in selected patients

SURGERY

  • Surgery rarely done

  • Surgical exclusion of right atrium

  • Intraoperative cryoablation

MONITORING

  • Monitor heart rate and symptoms of cardiomyopathy

DIET AND ACTIVITY

  • General healthy lifestyle

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA

  • After control of heart failure

FOLLOW-UP

  • Frequent follow-up may be needed to titrate medications

  • Follow-up 2–4 weeks after radiofrequency ablation

COMPLICATIONS

  • Cardiomyopathy

  • Complications of radiofrequency ablation include:

    • – Need for a pacemaker

    • – Superior vena cava syndrome

PROGNOSIS

  • Patient may remain symptomatic, but mortality is uncommon except when associated with advanced heart failure

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