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Supraventricular Tachycardia with Aberrant Conduction


Presentation

  • Sudhansu Chokroverty—a world-recognized expert in sleep medicine—presents the third edition of Sleep Disorders Medicine for the latest developments in this rapidly expanding specialty, with coverage of neuroscience and clinical application.[books.google.com]
  • Presents a new chapter on recording and interpreting heart rhythms in patients with pacemakers. Includes new material on interpreting ECG findings associated with implantable cardioverter-defibrillators.[books.google.com]
  • In some patients with VT, they may not be in a state of collapse, but present with dizziness, palpitations, syncope, chest pain or heart failure. Some patients with SVT and poor ventricular function may present in a state of haemodynamic collapse.[patient.info]
  • However, tachycardias with a supraventricular origin can present as a BCT when associated with aberrant conduction or a pre-existing bundle branch block (see Figures 8 and 9).[rcemlearning.co.uk]
  • Unfortunately, this is only present in 30% of all VT’s.[clinicaladvisor.com]
Physician
  • Widely considered the optimal electrocardiography reference for practicing physicians, and consistently rated as the best choice on the subject for board preparation, this is an ideal source for mastering the fundamental principles and clinical applications[books.google.com]
  • *Medscape Business of Medicine Academy Survey, September 2015 Learn from Experienced Professionals Courses were developed especially for physicians by business health experts and experienced physicians.[medscape.com]
  • Grauer has been a leading family physician educator for over 30 years. During that time he has published (as principal author) more than 15 books and numerous study aids on the topics of ECG interpretation, cardiac arrhythmias, and ACLS. Dr.[emergency-live.com]
  • However, electrical cardioversion is safer if you are skilled at procedural sedation, as most emergency physicians are. Chemical cardioversion (with the exception of adenosine) carries a high risk of hypotension, prolonged QT, and pro-arrhythmia.[epmonthly.com]
  • Many modern-day cardiac physicians are disconnected from clinical reality and are obsessed with complex EP concepts and end up with a miserable face in the bed side ! This is not a new revelation in 2013. Masood Akthar told this three decades ago.[drsvenkatesan.com]
Collapse
  • In some patients with VT, they may not be in a state of collapse, but present with dizziness, palpitations, syncope, chest pain or heart failure. Some patients with SVT and poor ventricular function may present in a state of haemodynamic collapse.[patient.info]
  • Dose can be repeated Should not be given to pediatric patients as there are reports of profound hypotension and circulatory collapse Cardiac troponin is commonly elevated in patients with AVNRT but is often not associated with coronary artery disease[coreem.net]
  • These symptoms and signs may be mild (consisting of dizziness or light-headedness), moderate (eg. chest pain or shortness of breath), or severe (with cardiovascular collapse or profound shock).[rcemlearning.co.uk]
Congestive Heart Failure
  • For example, mitral stenosis or regurgitation murmurs may point to atrial arrhythmias, and signs of congestive heart failure toward VT.[clinicaladvisor.com]
  • heart failure Cardiomyopathy Family history of sudden cardiac death (suggesting conditions such as HOCM, congenital long QT syndrome, Brugada syndrome or arrhythmogenic right ventricular dysplasia that are associated with episodes of VT) The likelihood[lifeinthefastlane.com]
Swelling
  • There were abrasions to the right thigh, and pain and swelling in the right leg. 0739-0800 : Pillar and car door cut away, and patient put onto spinal board The patient received a total of 1.5 L of crystalloid intravenously (IV) and 7.5 mg of morphine[ecgmojo.com]
Tachycardia
  • Ventricular Tachycardia in Nonischemic Dilated Cardiomyopathy 535 Electrocardiogram Characteristics of Outflow Tract Ventricular Tachycardia 553 Fascicular Tachycardia 567 Ventricular Tachycardia Originating from Unusual Sites 581 Electrocardiographic[books.google.com]
  • Abstract A description is given of a patient with an atrioventricular nodal tachycardia with left aberrant conduction changing into nonaberrant conduction after a ventricular premature beat.[link.springer.com]
  • These tachycardias are diverse; as such, the pathophysiology behind each form of WCT includes toxic, metabolic, and conduction system dysfunction mechanisms.[ncbi.nlm.nih.gov]
  • […] supraventricular, supraventricular tachycardias, Supraventricular tachycardia (SVtach), Supraventricular tachycardia NOS (disorder), SVT - Supraventricular tachycardia, Supraventricular tachycardia (disorder), supraventricular; tachycardia, tachycardia[fpnotebook.com]
  • SUPRAVENTRICULAR , Supraventric. tachycardia NOS , Supraventricular tachycardia NOS , SVT - Supraventricular tachy , supraventricular tachycardia (diagnosis) , supraventricular tachycardia , Tachycardia supraventricular , Tachycardia, Supraventricular[fpnotebook.com]
Heart Disease
  • Patients with ischemic heart disease, scar, systolic dysfunction and underlying conduction abnormalities are more likely to present with ventricular tachycardia.[clinicaladvisor.com]
  • Surprisingly, some patients with severe heart disease may tolerate sustained VT remarkably well and remain asymptomatic.[rcemlearning.co.uk]
  • This is a frequent finding among healthy individuals and in those with heart disease. If such aberration occurs at normal heart rate ( Ashman’s phenomenon : This type of aberration occurs when the RR interval is first prolonged and then shortened.[ecgwaves.com]
Palpitations
  • Your patient is a 40-year-old man who presents to the emergency department with palpitations and the 12-lead ECG shown in Figure 1. No prior ECG is available. The patient had previously been healthy.[ecg-interpretation.blogspot.com]
  • Wide-complex Tachycardia: Ventricular Tachycardia This ECG is from a man who was experiencing palpitations and light-headedness with near-syncope. On first look, you will see a wide-complex tachycardia (WTC) with a rate around 240 per minute.[ecgguru.com]
  • Some of the more common complaints include palpitations, lightheadness/dizziness, dyspnea, chest discomfort, flushing, presyncope and rarely syncope.[clinicaladvisor.com]
  • In some patients with VT, they may not be in a state of collapse, but present with dizziness, palpitations, syncope, chest pain or heart failure. Some patients with SVT and poor ventricular function may present in a state of haemodynamic collapse.[patient.info]
  • Case Report A 78-year-old woman presented to our hospital with palpitations and chest discomfort. She had a 6-year history of non-ST segment elevation myocardial infarction (MI); however, she had not received treatment.[e-arrhythmia.org]
Heart Failure
  • Features new chapters on pediatric electrocardiography that explore rhythm problems associated with pediatric obesity, heart failure, and athletic activity.[books.google.com]
  • In some patients with VT, they may not be in a state of collapse, but present with dizziness, palpitations, syncope, chest pain or heart failure. Some patients with SVT and poor ventricular function may present in a state of haemodynamic collapse.[patient.info]
  • For example, mitral stenosis or regurgitation murmurs may point to atrial arrhythmias, and signs of congestive heart failure toward VT.[clinicaladvisor.com]
  • failure Cardiomyopathy Family history of sudden cardiac death (suggesting conditions such as HOCM, congenital long QT syndrome, Brugada syndrome or arrhythmogenic right ventricular dysplasia that are associated with episodes of VT) The likelihood of[lifeinthefastlane.com]
Suggestibility
  • The following criteria suggest a supraventricular rhythm with aberrancy rather than VT: 1. A bundle branch morphology identical to that of the previous 12-lead ECG 2. An ectopic P wave that precedes the QRS complex 3.[aibolita.com]
  • (iii) In RBBB pattern tachycardia, a monophasic or biphasic waveform in lead V1 suggests VT and a triphasic RSR, rSR configuration suggests SVT. (iv) A 40 change in axis between sinus rhythm and tachycardia is an independent predictor of VT.[e-arrhythmia.org]
  • A monomorphic tachycardia with a positive complex in aVR suggests the axis is bizarre and is very suggestive of a ventricular origin.[rcemlearning.co.uk]
  • Wide complex tachycardia is often incorrectly diagnosed as supraventricular tachycardia when, in fact, the 12-lead electrocardiogram strongly suggests ventricular tachycardia.[annals.org]
  • If the V1 QRS is triphasic, Wellens’ criteria suggests investigation of V6 for an R:S ratio 10. ‘Rabbit ears’ Rsr’ VT.[slideshare.net]
Impulsivity
  • Moe, GK, Mendez, C, and Han, J: Aberrant A-V impulse propagation in the dog heart: A study of functional bundle branch block. Circulation Research 16: 261, 1965.[link.springer.com]
  • Answer to ECG challenge Premature atiral impulses are normally conducted to the ventricles with norrow QRS complexes very similar to a normal sinus impulse.[afghanheart.wordpress.com]
  • ( air conduction ) conduction of sound waves to the organ of hearing in the inner ear through the air. anterograde conduction 1. forward conduction of impulses through a nerve. 2. in the heart, conduction of impulses from atria to ventricles. atrioventricular[medical-dictionary.thefreedictionary.com]
  • The supraventricular impulse reaches the His-Purkinje system while the right bundle branch is still refractory and therefore blocks the impulse.[ecgwaves.com]
  • In the ventricle, the impulse from the fast pathway tries to go up the slow pathway but is blocked by the impulse coming down.[quizlet.com]
Insomnia
  • Demonstrates how recent basic science advances affect clinical medicine through new chapters on Sleep Deprivation and Sleepiness; Sleep and Memory Consolidation; Neuroimaging in Sleep and Sleep Disorders; Nutrition and Sleep; Nature and Treatment of Insomnia[books.google.com]

Workup

  • Disposition: The vast majority of patients with an episode of ventricular tachycardia should be admitted to the hospital (preferably a high-acuity setting) for further workup with cardiology or electrophysiology.[emdocs.net]
  • Syncope or severe symptoms occurring with palpitations, should always result in a formal cardiac workup. Syncope only occurs in about 15% of patients with SVT.[clinicaladvisor.com]
Wide QRS Complex
  • If the impulse is too premature, it may find one of the bundle branches still refractory from the previous impulse and will be conducted with a wide QRS complex. these premature atrial impulses that are followed by wide QRS complexes are aberrantly conducted[afghanheart.wordpress.com]
  • This results in bundle branch block and hence " wide QRS complex ". Clinical significance Identification of the wide QRS complex as aberration helps to exclude the diagnosis of VPS. ECG 1a.[metealpaslan.com]
  • Several criteria have been described for differentiation between VT and SVT in the presence of a wide QRS complex. We report a case of wide QRS complex tachycardia with left BBB (LBBB) morphology and a retrograde P wave on the surface ECG.[e-arrhythmia.org]
  • New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia. Heart Rhythm , 5 (1), 89-98. [7]Szelényi, Zsuzsanna, et al.[everydayebm.org]
  • QRS Complex Ventricular tachycardia (VT) is uncommon in children but can be rapidly fatal.[nhcps.com]
Prolonged PR Interval
  • The characteristic features of TCA toxicity are: Tachycardia — this is often a sinus tachycardia with a grossly prolonged PR interval, such that the P wave is hidden in the previous T wave or QRS complex; may be difficult to differentiate from junctional[lifeinthefastlane.com]
Right Bundle Branch Block
  • This can be either a left or right bundle branch block pattern. The following criteria suggest a supraventricular rhythm with aberrancy rather than VT: 1. A bundle branch morphology identical to that of the previous 12-lead ECG 2.[aibolita.com]
  • These aberrantly conducted beats typically have right bundle branch block morphology.[ecgwaves.com]
  • Figure 2 – The postcardioversion ECG showed normal sinus rhythm with right bundle-branch block.[consultant360.com]
  • Aberrantly conducted atrial impulses usually right bundle branch block configuration with rSR pattern in V1 because the right bundle branch has a longer refractory period than the left bundle branch in most individual. please click here for more information[afghanheart.wordpress.com]
  • Even though right bundle branch block aberrancy is more common than left bundle branch block aberrancy, both are possible. Additionally, we know that many patients have underlying bundle branch block, including bifascicular block, at baseline.[aclsmedicaltraining.com]
Bifascicular Block
  • In other words, typical RBBB, typical LBBB, typical bifascicular block (RBBB/LAFB), and typical bifascicular block (RBBB/LPFB). Having said that, just because the ECG shows a typical pattern, that doesn’t mean the ECG shows SVT![ems12lead.com]
  • Additionally, we know that many patients have underlying bundle branch block, including bifascicular block, at baseline. When a patient with a bundle branch block experiences SVT the result is a wide complex tachycardia.[aclsmedicaltraining.com]
  • QRS morphology in Figure 1 is consistent with a pattern of bifascicular block ( RBBB/LAHB ) — albeit uncertainty about the presence of a small initial r wave for the RBBB pattern seen in lead V1 is a bit atypical.[ecg-interpretation.blogspot.com]
Nodal Tachycardia
  • Abstract A description is given of a patient with an atrioventricular nodal tachycardia with left aberrant conduction changing into nonaberrant conduction after a ventricular premature beat.[link.springer.com]
  • Nonparoxysmal AV nodal tachycardia. Circulation 1957;16:1022 PubMed Google Scholar 5. Coumel P. Junctional reciprocating tachycardias: The permanent and paroxysmal forms of AV nodal reciprocating tachycardias.[link.springer.com]
P Wave Absent
  • SINUS TACHYCARDIA SUPRAVENTRICULAR TACHYCARDIA Infant: 220 bpm Infant: 220 bpm Child: 180 bpm Child: 180 bpm Slow onset Abrupt start/stop Fever, hypovolemia Pulmonary edema Varies with stimulation Constant, fast rate Visible P waves Absent P waves Table[nhcps.com]
Cannon A-Waves
  • Irregular cannon A waves can be seen in VT (if AV dissociation is present). Signs of hyperthyroidism such as thyroid bruit or exophthalmos may raise the possibility of hyperthyroidism and subsequent tachyarrhythmias.[clinicaladvisor.com]
Ventricular Hypertrophy
  • Observation upon ventricular hypertrophy with especial reference to preponderance of one or other chamber. ‎ Seite 478 - Brugada P. Brugada J.[books.google.de]
Abnormal ECG
  • Comprehensively and expertly describes how to capture and interpret all normal and abnormal ECG findings in adults and children.[books.google.com]

Treatment

  • In addition to summarizing basic science and important technological aspects of diagnosis and treatment, this edition presents new chapters—on sleep and memory consolidation, neuroimaging, and more—in a color layout that makes it easy to access the latest[books.google.com]
  • The treatment for all unstable patients is synchronized electrical cardioversion. Contact[aibolita.com]
  • Treatment: In any patient compromised by their monomorphic VT the treatment of choice is DC cardioversion.[rcemlearning.co.uk]
  • General Treatment Principles Treatment should be based on the ventricular rate, not the atrial rate Example: Atrial flutter with 4:1 or 5:1 with a ventricular rate of 30 should be treated as an bradydysrhythmia.[maryland.ccproject.com]
  • Treatment Considerations – Sustained fascicular VT responds extremely well to treatment with IV verapamil ( proposed role for slow inward calcium channel in genesis of the arrhythmia ) — and this is the treatment of choice when the arrhythmia is recognized[ecg-interpretation.blogspot.com]

Prognosis

  • This arrhythmia is usually stable and the prognosis is much more favorable than VT. It is usually treated with vagal maneuvers or adenosine. What does aberrancy mean? You can think of “aberrancy” as abnormal conduction.[aclsmedicaltraining.com]
  • Prognosis Monomorphic VT usually occurs after myocardial infarction and is a sign of extensive myocardial damage; there is a high mortality, often resulting from impaired ventricular function.[patient.info]
  • VT is the most important differential diagnosis because of its unfavorable prognosis. An accurate diagnosis with immediate treatment is usually required.[e-arrhythmia.org]

Etiology

  • That said — IF there is any doubt about etiology — verapamil/diltiazem should not be given for WCT.[ecg-interpretation.blogspot.com]
  • Etiology: 1. Enhanced Automaticity 2. Triggered Activity: Early Afterdepolarization (EAD's) 3.[quizlet.com]

Pathophysiology

  • These tachycardias are diverse; as such, the pathophysiology behind each form of WCT includes toxic, metabolic, and conduction system dysfunction mechanisms.[ncbi.nlm.nih.gov]
  • Pathophysiology A sudden change in the length of the previous cardiac cycle results in a refractory right or left bundle branch. Refractoriness in any bundle branch does not allow the supraventricular impulse to propagate in that branch.[metealpaslan.com]

Prevention

  • Preventing complications of adenosine administration. Ann Emerg Med 2002;39:347–8 PubMed CrossRef Google Scholar 8. Chang M, Wrenn K. Adenosine dose should be less when administered through a central line.[link.springer.com]
  • Presumably it will also respond to IV diltiazem — though the effectiveness of oral calcium blockers for preventing recurrence is variable.[ecg-interpretation.blogspot.com]

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