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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Progressive cyclic variation in P-wave morphology

  • Heart rate 60–100 bpm

  • Variation of P-wave morphology, P-P interval, and P-R interval

GENERAL CONSIDERATIONS

  • This rhythm is benign

  • This rhythm and multifocal atrial tachycardia are similar except for heart rate

  • The other possible explanation is that there is significant respiratory sinus arrhythmia, with uncovering of latent foci of pacemaker activity

  • Usually, it is associated with underlying lung disease

  • In the elderly, it may be a manifestation of sick sinus syndrome

  • In the young and athletic heart, it may represent enhanced vagal tone

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Usually causes no symptoms and is incidentally discovered

  • Occasional patient may feel skipped beats

PHYSICAL EXAM FINDINGS

  • Variable S1

DIFFERENTIAL DIAGNOSIS

  • Multifocal atrial tachycardia (heart rate > 100 bpm)

  • Frequent premature atrial complexes and atrial bigeminy

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • None specific

ELECTROCARDIOGRAPHY

  • ECG to document rhythm

TREATMENT

CARDIOLOGY REFERRAL

  • Not required

MEDICATIONS

  • No specific treatment

  • Monitor and treat the underlying cause, such as sick sinus syndrome or lung disease

DIET AND ACTIVITY

  • No restrictions

  • General healthy lifestyle

ONGOING MANAGEMENT

FOLLOW-UP

  • Once a year if sinus node abnormality is suspected; otherwise when symptoms arise

COMPLICATIONS

  • May progress to sick sinus syndrome

PROGNOSIS

  • This condition by itself is benign

RESOURCES

PRACTICE GUIDELINES

  • Indications for pacemaker:

    • – If part of sick sinus syndrome

    • – If associated with documented symptomatic bradycardia

REFERENCES

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Page  RL, Joglar  JA, Caldwell  MA,  et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2016;133:e506.  [PubMed: 26399663]

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