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Nonsustained Ventricular Tachycardia

Nonsustained ventricular tachycardia was defined in different manners over the years, as 3 to 5 consecutive ventricular premature contractions (whose pacemaker is located below the atrioventricular node), lasting for less than 30 seconds or as more than 16 consecutive ventricular extrasystoles, causing a heart rate above 120 or 125 beats/minute. This poorly reproducible arrhythmia is an overall mortality predictor, especially in patients with structural heart disease.


Presentation

Nonsustained ventricular tachycardia is usually asymptomatic because of its short duration, but some patients complain about palpitations. It can be recorded at rest in asymptomatic individuals [1] and it can be a part of the “athlete's heart syndrome” [2]. In trained athletes with no structural heart disease, genetic channelopathies and early repolarization, it is considered to be benign, as it disappears during deconditioning periods [3]. However, the physician must inquire about the use of potentially proarrhythmic drugs and personal and familial history of heart disease, syncope and sudden death [4].

Longer arrhythmic episodes can cause lightheadedness and anxiety. Syncope, diaphoresis, pallor, hypotension and dyspnea are not usually encountered with nonsustained ventricular tachycardia episodes, but rather with sustained ones. Physical examination may reveal cannon a-waves if atrial fibrillation or flutter is absent and a variation of the first heart sound’s intensity on auscultation. However, these findings are only present during the acute episode, therefore the physician only finds them if he or she examines the patient during those few seconds, so the patient must have already been admitted to a hospital.

Recurrent Pulmonary Embolism
  • Inferior vena cava filters are commonly used to prevent pulmonary embolism in patients who manifest deep vein thrombosis and recurrent pulmonary embolism despite anticoagulation, or in patients with contraindications to anticoagulation.[ncbi.nlm.nih.gov]
Heart Disease
  • Therefore, establishing the presence or absence of structural or inherited heart disease is a critical step in each patient's evaluation.[ncbi.nlm.nih.gov]
  • Abstract Nonsustained ventricular tachycardia is not uncommon both in the presence and absence of organic heart disease and in the latter situation, is usually not associated with an increased risk.[ncbi.nlm.nih.gov]
  • This poorly reproducible arrhythmia is an overall mortality predictor, especially in patients with structural heart disease.[symptoma.com]
  • Abstract In patients with structural heart disease, ventricular arrhythmias are associated with an increased risk of overall mortality and sudden cardiac death (SCD).[ncbi.nlm.nih.gov]
Cardiac Signs and Symptoms
  • The book and DVD package is designed to provide comprehensive coverage of every aspect of cardiovascular medicine from cardiac signs and symptoms and the full range of cardiac imaging techniques through management of peripheral vascular disease and the[books.google.it]

Workup

Nonsustained ventricular tachycardia patients must undergo a thorough cardiac evaluation. The most frequent causes of the disease in middle-aged individuals are myocardial ischemia, valve diseases and cardiomyopathies, whereas younger people may suffer from long QT syndrome, arrhythmogenic right ventricular cardiomyopathy or Brugada syndrome.

Blood workup should include potassium, calcium, magnesium and phosphate evaluation, as well as measurement of serum digoxin and tricyclic antidepressants levels or toxicology screening where appropriate. Cardiac troponins should also be measured when acute myocardial ischemia is suspected.

A simple electrocardiogram is able to pinpoint the approximate location of the ventricular contractions and to describe the tachycardia as monomorphic or polymorphic. The location of the R/S transition may predict the presence of arrhythmogenic right ventricular cardiomyopathy [5], whereas the duration of the cardiac cycle during the episode is an indicator of concomitant polymorphic ventricular tachycardia [6]. Holter monitoring is usually indicated in symptomatic patients and accurately describes arrhythmic episodes [7]. Further information is added by electrophysiology testing. In patients where arrhythmic episodes can be induced, the mortality risk is higher [8].

Some episodes are exercise-induced and may be caused by ventricular outflow arrhythmias [9]. Right ventricular outflow ectopic loci cause a left bundle branch block pattern, whereas those located in the left ventricle outflow tract appear as right bundle branch block complexes. Structural abnormalities of these areas can be demonstrated by magnetic resonance imaging or myocardial biopsy [10] [11].

Echocardiography is another useful tool, as it is able to describe myocardial scars (visualized as akinetic regions), left ventricular hypertrophy (an indicator of long-term hypertension) and the presence and severity of valvulopathies. Cardiomegaly also predicts nonsustained ventricular tachycardia episodes [12]. If the arrhythmia is detected during the recovery period of an exercise test, it indicates cardiovascular mortality during the next decades [13].

Wide QRS Complex
  • Class I antiarrhythmic drugs, tricyclic antidepressants and hyperkalemia may also cause very wide QRS complexes.[ecgwaves.com]
  • Andries A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex Circulation, 83 (1991), pp. 1649-1659 [4.] G.F. Van Hare, P.[analesdepediatria.org]
  • Depending on the etiology, onset of ventricular tachycardia can be paroxysmal (sudden) or nonparoxysmal, its wide qrs complexes can be uniform or polymorphic, and the ventricular beating may be independent of the atrial beating (av dissociation).[icd10data.com]
  • "A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex". Circulation. 83 (5): 1649–59. doi : 10.1161/01.cir.83.5.1649. PMID 2022022. Baerman JM, Morady F, DiCarlo LA, de Buitleir M (January 1987).[en.wikipedia.org]
  • Wide QRS complexes ( 120 ms). Presence of AV dissociation. Fusion beats. Retrograde ventriculoatrial conduction may occur, which can generate an ECG complex similar to PSVT with aberrant conduction.[patient.info]
T Wave Alternans
  • We examined whether T-wave alternans (TWA) level is correlated with nonsustained ventricular tachycardia (NSVT) incidence in association with PCI in patients with acute ST-segment elevation myocardial infarction (STEMI).[ncbi.nlm.nih.gov]
  • OBJECTIVE: Microvolt T-wave Alternans (TWA) is associated with abnormal repolarization and predicts arrhythmic mortality in patients with previous myocardial infarction (MI).[ncbi.nlm.nih.gov]
  • Alternans T-wave alternans (TWA) is a test that is thought to reflect dispersion of repolarization and has been shown to predict VT inducibility and future arrhythmic events better than SAECG. 101 In patients similar to those in MADIT II, a microvolt[clinicalgate.com]
  • Promising results on the predictive ability of T-wave alternans tests have not been consistent ( 90–92 ). In patients with LVEF 93 ).[onlinejacc.org]
  • Signal-averaged ECG, baroreflex sensitivity, heart rate variability, and T-wave alternans were not helpful for arrhythmia risk stratification.[academic.oup.com]
Myocardial Fibrosis
  • However, chronic, high-intensity exercise sometimes has harmful effects on cardiac health, and pathologic changes, such as myocardial fibrosis, have been observed in endurance athletes.[ncbi.nlm.nih.gov]
  • PURPOSE: Late gadolinium enhancement (LGE) during cardiac magnetic resonance imaging (MRI) can be seen in patients with myocardial fibrosis accompanied by myocardial infarction and cardiomyopathy.[ncbi.nlm.nih.gov]
  • In another report, NSVT, but not myocardial fibrosis, was an independent predictor of arrhythmic events and death ( 130 ).[onlinejacc.org]

Treatment

  • HYPOTHESIS: Provided that early and intensive lipid-lowering treatment can reduce ventricular premature beat or non-sustained ventricular tachycardia after ACS.[ncbi.nlm.nih.gov]
  • Nonetheless, the results of therapy with many of the treatment programs described are encouraging, as exemplified by the report from Graboys and coworkers.[ncbi.nlm.nih.gov]
  • Assuming NSVT as a potential prognostic marker for sudden death, amiodarone treatment may have exerted a beneficial effect in these patients, but this statement is only a presumption due to the limitations of our study.[ncbi.nlm.nih.gov]
  • It is important to approach a wide-complex tachycardia in a systematic manner, to ensure correct diagnosis and treatment.[ncbi.nlm.nih.gov]
  • In MUSTT, patients received no survival benefit with electrophysiologically guided drug treatment.[ncbi.nlm.nih.gov]

Prognosis

  • The results suggest that the prognosis for arrhythmic death in these patients is not necessarily benign.[ncbi.nlm.nih.gov]
  • Abstract In a group of 191 postinfarction patients, the low variability of cycle lengths in nonsustained ventricular tachycardia was associated with poor prognosis during follow-up.[ncbi.nlm.nih.gov]
  • When NSVT occurs in patients with normal hearts, it usually has a benign prognosis. Therefore, establishing the presence or absence of structural or inherited heart disease is a critical step in each patient's evaluation.[ncbi.nlm.nih.gov]
  • MUSTT also demonstrated that untreated patients with inducible sustained VT had a worse prognosis than patients in whom sustained VT could not be initiated at electrophysiologic study.[ncbi.nlm.nih.gov]
  • Although NSVT that occurs within the first several hours of presentation does not have an associated adverse prognosis, NSVT that occurs beyond the first several hours after presentation is associated with significant increases in relative risk.[ncbi.nlm.nih.gov]

Etiology

  • This article reviews the supporting evidence for the therapeutic options available for these patients according to the etiology of the reduced ejection fraction.[ncbi.nlm.nih.gov]
  • & control Defibrillators, Implantable Electrocardiography, Ambulatory* Female Humans Male Middle Aged Prevalence Retrospective Studies Risk Assessment Tachycardia, Ventricular/diagnosis* Tachycardia, Ventricular/epidemiology Tachycardia, Ventricular/etiology[ncbi.nlm.nih.gov]
  • Patients were then stratified by the etiology (ischemic or nonischemic) of cardiomyopathy.[ncbi.nlm.nih.gov]
  • When adjusted for preoperative age, gender, etiology or antiarrhythmics, both postoperative VT and RVEF predicted CD (p 0.05). When postoperative VT and RVEF were both in the multivariable model, only subnormal RVEF predicted CD (p 0.04).[ncbi.nlm.nih.gov]
  • Patients without (group 1) and with (group 2) NSVT were balanced for variables: age, etiology of heart disease, New York Heart Association (NYHA) functional class, use of amiodarone and diuretics and left ventricular diameter by echocardiogram.[ncbi.nlm.nih.gov]

Epidemiology

  • , Ambulatory* Female Humans Male Middle Aged Prevalence Retrospective Studies Risk Assessment Tachycardia, Ventricular/diagnosis* Tachycardia, Ventricular/epidemiology Tachycardia, Ventricular/etiology Time Factors[ncbi.nlm.nih.gov]
  • This is true despite a wealth of epidemiologic and basic/clinical laboratory findings that have accumulated during the past 2 decades.[ncbi.nlm.nih.gov]
  • Given the epidemiology of SCD, the normal EF group is an extremely desirable target for intervention. However, in the MERLIN TIMI-36 clinical trial population, even the highest risk group had a SCD rate of only 4.3% at one year.[circ.ahajournals.org]
  • , urgent angiography if ischemia not excluded (I, C) 1 Correction of electrolyte abnormalities (specifically hypokalemia) may decrease progression to VF. 2 ECG’s Definition 3,4 3-5 consecutive beats originating below the AV node Rate 100bpm Duration Epidemiology[ddxof.com]
  • Sackett , DL , Haynes , RB , Guyatt , GH , Tugwell , P Clinical Epidemiology: A Basic Science for Clinical Medicine . Little, Brown , Boston , 1991 , p 55 . 7. Proclemer , A , Facchin , D , Miani , D , Feruglio , GA .[cambridge.org]
Sex distribution
Age distribution

Pathophysiology

  • Cardiovascular Magnetic Resonance and XRay Computed Tomography 245 Choosing Appropriate Imaging Techniques 269 DISORDERS OF RHYTHM AND CONDUCTION 283 Electrophysiology of Cardiac Arrhythmias 285 Treatment of Cardiac Arrhythmias 305 Syncope 329 HEART FAILURE 345 Pathophysiology[books.google.com]
  • The sympathetic nervous system in heart failure physiology, pathophysiology, and clinical implications.[scielo.br]
  • Markides V, Schilling RJ (2003) Atrial fibrillation: classification, pathophysiology, mechanisms and drug treatment. Heart 89: 939-943.[omicsonline.org]
  • ., long-QT syndrome ), catecholaminergic polymorphic ventricular tachycardia, arrhythmogenic right ventricular dysplasia, or a heart attack. [1] [2] Pathophysiology [ edit ] The morphology of the tachycardia depends on its cause and the origin of the[en.wikipedia.org]
  • Development of arrhythmias in the patient with congestive heart failure: pathophysiology, prevalence and prognosis. Am J Cardiol. 1986;57(3):3B-7B. Kinder C, Tamburro P, Kopp D, Kall J, Olshansky B, Wilber D.[anesthesia.ucsf.edu]

Prevention

  • These results support the need for ICD implantation for primary prevention, with attention to careful programming of the detection rate to prevent inappropriate therapy.[ncbi.nlm.nih.gov]
  • Accordingly, the use of nonsustained VT to select patients for primary implantable cardioverter/defibrillator prevention trials shortly after AMI appears to be limited.[ncbi.nlm.nih.gov]
  • Amiodarone has been used widely in these patients but its value in preventing sudden death is still uncertain.[ncbi.nlm.nih.gov]
  • Abortive shock capability (noncommitted shocks) is a feature available in devices to prevent delivery of shocks for nonsustained VT.[ncbi.nlm.nih.gov]
  • Inferior vena cava filters are commonly used to prevent pulmonary embolism in patients who manifest deep vein thrombosis and recurrent pulmonary embolism despite anticoagulation, or in patients with contraindications to anticoagulation.[ncbi.nlm.nih.gov]

References

Article

  1. Engstrom G, Hedblad B, Janzon L, et al. Ventricular arrhythmias during 24-h ambulatory ECG recording: incidence, risk factors and prognosis in men with and without a history of cardiovascular disease. J Intern Med.1999;246:363–72.
  2. Biffi A, Maron BJ, Verdile L, et al. Impact of physical deconditioning on ventricular tachyarrhythmias in trained athletes. J Am Coll Cardiol.2004; 44:1053–8.
  3. Biffi A, Maron BJ, Culasso F, et al. Patterns of ventricular tachyarrhythmias associated with training, deconditioning and retraining in elite athletes without cardiovascular abnormalities. Am J Cardiol.2011;107:697–703.
  4. Zipes DP, Camm AJ, Borggrefe M, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. J Am Coll Cardiol. 2006; 48(5):e247-346.
  5. Hoffmayer KS, Machado ON, Marcus GM, et al. Electrocardiographic comparison of ventricular arrhythmias in patients with arrhythmogenic right ventricular cardiomyopathy and right ventricular outflow tract tachycardia. J Am Coll Cardiol. 2011;58:831–8.
  6. Shimizu W. Arrhythmias originating from the right ventricular outflow tract: how to distinguish “malignant” from “benign”? Heart Rhythm. 2009; 6:1507–11.
  7. Pastor-Pérez FJ, Manzano-Fernández S, Goya-Esteban R, et al. Comparison of detection of arrhythmias in patients with chronic heart failure secondary to non-ischemic versus ischemic cardiomyopathy by 1 versus 7-day Holter monitoring. Am J Cardiol. 2010;106:677–81.
  8. Buxton AE, Lee KL, DiCarlo L, et al. Electrophysiologic testing to identify patients with coronary artery disease who are at risk for sudden death: Multicenter Unsustained Tachycardia Trial Investigators. N Engl J Med. 2000;342:1937–45.
  9. Kim RJ, Iwai S, Markowitz SM, et al. Clinical and electrophysiological spectrum of idiopathic ventricular outflow tract arrhythmias. J Am Coll Cardiol. 2007;49:2035–43.
  10. Carlson MD, White RD, Trohman RG, et al. Right ventricular outflow tract ventricular tachycardia: detection of previously unrecognized anatomic abnormalities using cine magnetic resonance imaging. J Am Coll Cardiol. 1004;24:720–7.
  11. Chimenti C, Calabrese F, Thiene G, et al. Inflammatory left ventricular microaneurysms as a cause of apparently idiopathic ventricular tachyarrhythmias. Circulation. 2001;104:168–73.
  12. Di Bella G, Passino C, Aquaro GD, et al. Different substrates of non-sustained ventricular tachycardia in post-infarction patients with and without left ventricular dilatation. J Card Fail. 2010;16:61–8.
  13. Katritsis DG, Zareba W, Camm AJ.Nonsustained ventricular tachycardia. J Am Coll Cardiol. 2012;60(20):1993-2004.

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Last updated: 2019-07-11 20:00