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Tachyarrhythmia

Tachyarrhythmias

Tachyarrhythmia is an abnormal cardiac rhythm with a heart rate of 100 or more beats per minute. It may be asymptomatic or highly symptomatic and life-threatening. A 12-lead electrocardiogram forms the mainstay of diagnosis.


Presentation

Tachyarrhythmia is a type of abnormal cardiac rhythm and is classified based on its site of origin as ventricular (originating below the bundle of His) or supraventricular (above the bundle of His). Ventricular tachyarrhythmias include ventricular tachycardia (VT), ventricular fibrillation (VF), and premature ventricular contraction (PVC). Supraventricular tachycardia (SVT) or paroxysmal supraventricular tachycardia (PSVT) presents a rapid heart rate anywhere between 150-250 beats per minute and is further classified as atrioventricular nodal reentrant tachycardia (AVNRT), atrioventricular reciprocating tachycardia (AVRT), atrial tachycardia (AT), atrial fibrillation and atrial flutter. The clinical presentation of tachyarrhythmias may vary depending on the type of arrhythmia from asymptomatic to chronic and recurrent or highly symptomatic and life threatening. Common symptoms in all tachyarrhythmias include palpitations, chest discomfort, dyspnea, fatigue, lightheadedness, and dizziness. Uncommon symptoms comprise diaphoresis, nausea, presyncope, and syncope.

VT is a tachyarrhythmia of >100 beats per minute which is regular while VF is a more serious type of tachyarrhythmia with an asynchronous discharge of impulses causing the heart to beat erratically, often at a rate > 300 beats per minute. This results in poor perfusion of organs, especially the brain, with possible fatal outcomes. VF is commonly seen in individuals with cardiac disease or a recent history of myocardial infarction. PVCs are a less serious type of tachyarrhythmia with the ventricle contracting prematurely and out of sequence to the normal heart beat. They often start suddenly without a warning and can be stimulated by caffeine, chocolate, and some medicines.

The commonest type of SVT is AVNRT which affects young, healthy women [1], often without structural cardiac disease, though some patients may have pericarditis, previous myocardial infarction, or mitral valve prolapse [2]. AVRT is the second most common type of SVT and is caused by accessory tracts which conduct the abnormal impulses proximally as well as distally creating a reentry circuit [3]. AVRT can occasionally occur with Wolff-Parkinson-White syndrome and may spontaneously degenerate into atrial fibrillation [4]. AT is the third most common type of SVT arising from a focus in the atrium [5]. It is of two types: focal and multifocal AT (MAT). Focal AT originates from a definite focus like the crista terminalis in the right atrium or the ostia of the pulmonary veins in the left atrium [6] [7]. MAT is frequently seen in patients with congestive heart failure or chronic obstructive pulmonary disease [6]. SVT symptoms depend on the patient's age, comorbid medical conditions, and duration of the episodes.

Atrial fibrillation (AF) is a type of SVT and a common cause of stroke and congestive heart failure [8]. Atrial flutter is an irregular SVT originating in the atria which may be asymptomatic in the initial stages or may be associated with palpitations, later degenerating into AF. Wolff-Parkinson-White syndrome is characterized by abnormal accessory conduction pathways (bundle of Kent) between the atria and the ventricle.

Dyspnea
  • Eventually, the fluid enters the air spaces in the lungs, reduces the amount of oxygen that can enter the blood, and causes shortness of breath (dyspnea).[answers.yahoo.com]
  • Common symptoms in all tachyarrhythmias include palpitations, chest discomfort, dyspnea, fatigue, lightheadedness, and dizziness. Uncommon symptoms comprise diaphoresis, nausea, presyncope, and syncope.[symptoma.com]
  • Also dyspnea in 35% and angina in 20%. Ventricular Tachycardia Any wide complex tachycardia in an ICU patient should be treated as a probably VT (95% of them are).[openanesthesia.org]
  • He developed pronounced dyspnea on exertion, and repeated ECGs and another Holter monitor now showed persistent AF.[doi.org]
  • Congestive heart failure was defined by clinical symptoms (dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea), physical examination (elevated jugular venous pressure, peripheral edema, weight gain), or pulmonary congestion on chest x-ray[dx.doi.org]
Nausea
  • Uncommon symptoms comprise diaphoresis, nausea, presyncope, and syncope.[symptoma.com]
  • California Shadi Lahham, MD, MS University of California, Irvine, Department of Emergency Medicine, Irvine, California Case presentation Diagnosis CASE PRESENTATION A 29-year-old female with no significant past medical history presented with palpitations, nausea[westjem.com]
Tachycardia
  • […] due to the accessory pathway, atrial ectopic tachycardia and permanent junctional reciprocal tachycardia).[ncbi.nlm.nih.gov]
  • , and eight had sustained ventricular tachycardia.[ncbi.nlm.nih.gov]
  • In fetuses with hydrops fetalis, digoxin had lower rates of tachycardia termination compared with flecainide (OR: 0.412; 95% CI, 0.268-0.632; I 2 0%).[ncbi.nlm.nih.gov]
  • Five junctional ectopic tachycardia, 2 atrial flutters, 1 paroxysmal supraventricular tachycardia, 1 atrial fibrillation, 1 atrioventricular reciprocating tachycardia with Wolff-Parkinson-White syndrome and 2 excessive sinus tachycardia were treated.[ncbi.nlm.nih.gov]
  • To our knowledge, there are few reports of a fetus with the long QT syndrome who exhibited ventricular tachycardia in utero.[ncbi.nlm.nih.gov]
Heart Disease
  • KEYWORDS: Amiodarone; Anti-arrhythmic drug; Congenital heart disease; Tachyarrhythmia[ncbi.nlm.nih.gov]
  • Twenty individuals had congenital heart disease. Common diagnoses were Wolff-Parkinson-White syndrome (n 27), focal atrial tachycardia (n 10), permanent junctional reciprocating tachycardia(n 6), and atrial flutter (n 6).[ncbi.nlm.nih.gov]
  • BACKGROUND: J wave is known to be associated with increased risk of life-threatening ventricular arrhythmias in both structural and nonstructural heart disease.[ncbi.nlm.nih.gov]
  • OBJECTIVES: We hypothesized that atrial tachycardia substrates after primary E-TCPC would be similar to those in other forms of congenital heart disease and that catheter ablation could be performed effectively using a primarily transconduit approach.[ncbi.nlm.nih.gov]
  • METHODS: A retrospective analysis was performed on 312 consecutive patients undergoing surgery for congenital heart disease. Twelve patients were treated with landiolol for critical tachyarrhythmia. The mean age of patients was 28.7 10.6 months.[ncbi.nlm.nih.gov]
Hypotension
  • One patient in the landiolol group showed hypotension and bradycardia, without serious consequences. CONCLUSIONS: Landiolol hydrochloride can be effectively and safely used in patients who develop tachyarrhythmia after esophagectomy.[ncbi.nlm.nih.gov]
  • Anatomical and clinical aspects, with major alterations (Vth degree hepatomegaly, polyserositis, peripheral edema, tachyarrhythmic heart contractions, hypotension, pallor accentuated by vasoconstriction) acutely installed in a previously healthy young[ncbi.nlm.nih.gov]
  • DC cardioversion is indicated in the setting of AF in 1) hypotension 2) impaired vital organ function or 3) HR 150. Always premedicate.[openanesthesia.org]
  • After tumor vein ligation, the landiolol was discontinued and her hemodynamics were stable without hypotension. This case demonstrates that landiolol is useful for treating pheochromocytoma-induced tachyarrhythmia safely without hypotension.[journals.lww.com]
  • Hypotension can occur in a small number of patients (vernakalant 7.6%, placebo 5.1%).[web.archive.org]
Cardiac Signs and Symptoms
  • Cardiac tumours are rare in childhood and should be considered as part of the differential diagnosis in a child presenting with cardiac signs and symptoms and treatment should be individualised for each patient.[um.edu.mt]
Hepatojugular Reflux
  • These clinical and paraclinical aspects were: stasis hepatomegaly with hepatojugular reflux, pulmonary congestion with stasis rales, peripheral edema, transudative polyserositis - pericarditis, hydrothorax, ascites, dilatation of inferior vena cava and[ncbi.nlm.nih.gov]
Dizziness
  • CASE DESCRIPTION: A 31-year-old female presented with atypical chest pain, palpitations, tachycardia, headaches, and dizziness for 2 years. Multiple antiarrhythmics and ultimately cardiac ablation procedure proved to be ineffective.[ncbi.nlm.nih.gov]
  • Temporarily discontinue ibrutinib in patients who develop signs or symptoms of ventricular tachyarrhythmia, including, but not limited to, palpitations, chest pain, dyspnoea, dizziness, or fainting.[gov.uk]
  • Other times, symptoms such as a rapid heart rate, pounding in the chest, dizziness, lightheadedness, fainting or near fainting can occur. The treatment will vary depending on the type of fast heartbeat and what is making it happen.[heart.emedtv.com]
  • Common symptoms in all tachyarrhythmias include palpitations, chest discomfort, dyspnea, fatigue, lightheadedness, and dizziness. Uncommon symptoms comprise diaphoresis, nausea, presyncope, and syncope.[symptoma.com]
  • While driving, 2 percent had a syncopal episode, 11 percent had dizziness or palpitations that necessitated stopping the vehicle, 22 percent had dizziness or palpitations that did not necessitate stopping the vehicle, and 8 percent of the 295 patients[nejm.org]

Workup

Tachyarrhythmias can be detected by history and physical examination but the diagnosis is confirmed by a 12-lead electrocardiogram (ECG) or a rhythm strip. Often SVT episodes are misdiagnosed as anxiety or panic attacks especially in the presence of a psychiatric disorder [8]. A high index of suspicion is, therefore, important to make a diagnosis [9]. The initial evaluation should determine whether a patient is hemodynamically stable. A brief cardiovascular examination will determine the ventricular rate and its regularity while the nature of the jugular venous pulse waves may also help to detect tachyarrhythmias. In a stable, symptomatic patient, it is important to obtain a 12-lead ECG while a rhythm strip is an initial assessment measure in an unstable patient prior to emergency cardioversion.

The ECG findings are characteristic for each tachyarrhythmia. A supraventricular origin of the tachyarrhythmia is indicated by a narrow QRS complex (< 0.12 sec) while a wide QRS complex (≥ 0.12 sec) indicates a ventricular origin or an SVT conducted by an intraventricular conduction defect or preexcitation in the Wolff-Parkinson-White syndrome. AF features are irregular, continuous, rapid beats at a rate >300 beats/ minute without discrete P waves. If the P waves are discrete and vary with every beat with at least 3 different morphologies then it is suggestive of MAT. Atrial flutter appears as regular, discrete, uniform P waves without intervening isoelectric periods at rates > 250 beats/min while AT features include regular, discrete, uniform, abnormal P waves with intervening isoelectric periods at rates < 250 beats/min. In VF, the rhythm strip will show rapid, irregular heart rate up to 300 beats/ minute. If the QRS complex varies with every beat, then the tachyarrhythmia is called polymorphic VT and the most notorious form of polymorphic VT is torsades de pointes.

Laboratory tests should include serum electrolytes, calcium, phosphate, as well as cardiac troponin level assessment. Echocardiography helps to assess the status of the heart while Holter monitoring is indicated in patients with recurrent tachyarrhythmias. Other tests like stress test may be performed as indicated during the clinical evaluation of the patient.

Treatment

  • AIM: The optimal treatment for foetal tachyarrhythmia remains controversial, and this study aimed to fill this gap in the knowledge.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Flecainide may be more effective treatment than digoxin as a first-line treatment for fetal supraventricular tachycardia. 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.[ncbi.nlm.nih.gov]
  • Relaxin treatment significantly attenuated tachyarrhythmia inducibility and cardiac dysfunction in healing infarcted heart.[ncbi.nlm.nih.gov]
  • This would imply that it is of the utmost importance to aim at immediate and complete control of the heart rate in the treatment of fetal tachyarrhythmia.[ncbi.nlm.nih.gov]
  • Improvement in LVEF within 6 months after treatment of index arrhythmia was observed in 41 patients, and LVEF did not improve in 30 patients.[ncbi.nlm.nih.gov]

Prognosis

  • Secondary effects of fetal circulation can be additionally assessed by: ductus venosus flow assessment umbilical vein flow assessment development of hydrops fetalis Treatment and prognosis Prognosis is somewhat dependent on the presence of hydrops.[radiopaedia.org]
  • The prognosis was dependent on the presence or absence of fetal hydrops and was not influenced by the type of arrhythmia or gestational age. 1987 S. Karger AG, Basel Article / Publication Details First-Page Preview[karger.com]
  • Although cardiac-related causes account for relatively a small proportion of cases of syncope (14%), they should always be excluded due to the worse prognosis (6).[caribbean.scielo.org]

Etiology

  • Abstract Observation of major pathological alterations in a young person involves etiological and clinical justifications, in order to properly assess, treat and control these conditions.[ncbi.nlm.nih.gov]
  • Further studies to elucidate the etiology and the timing of tachyarrhythmias after the Norwood procedure are necessary.[ncbi.nlm.nih.gov]
  • All instances of VT must be followed with an etiologic search, including EKG, ABG, chem-12, drug levels.[openanesthesia.org]
  • Etiology Mechanism divided into disorders of impulse conduction and impulse formation : Disorders of impulse conduction: Reentry is the most common mechanism of tachyarrhythmias.[unboundmedicine.com]

Epidemiology

  • Working Group on Epidemiology and Prevention of Cardiovascular Diseases: Meeting of the Working Group of the European Society of Cardiology on Epidemiology and Prevention of Cardiovascular Diseases 9,Suppl. 1 von: Weltgesundheitsorganisation.[zdb-katalog.de]
  • Anderson KP (2008) The changing epidemiology of ventricular arrhythmias. Cardiol Clin 26(3):321–333 CrossRef PubMed Google Scholar 67.[link.springer.com]
  • Nonetheless, it remains imperative that further research into AF epidemiology, genetics, detection, and treatments continues to push forward rapidly as the worldwide population ages dramatically over the next 20 years. HTML[doi.org]
  • The epidemiological features of AF are described in one of the largest population cohorts ever studied.[dx.doi.org]
  • Epidemiology. 14(6):666-672, NOV 2003 DOI: 10.1097/01.ede.0000091649.26364.c0 , PMID: 14569181 Issn Print: 1044-3983 Publication Date: 2003/11/01 Checking for direct PDF access through Ovid Abstract Atrial fibrillation is a common arrhythmia associated[doi.org]
Sex distribution
Age distribution

Pathophysiology

  • This review describes the pathophysiology and corresponding electrocardiographic findings of each arrhythmia. In addition, this summary compares the clinical findings, management, and outcomes of these arrhythmias during fetal and postnatal life.[neoreviews.aappublications.org]
  • Current research on AF support and explore the hypothesis that initiation and maintenance of AF require pathophysiological remodeling of the atria, either specifically as in lone AF or secondary to other heart disease as in heart failure‐associated AF[doi.org]
  • Our review focuses on the epidemiology and pathophysiology of AF rather than its clinical treatment. Figure 1.[dx.doi.org]
  • Importantly, to understand the pathophysiology and mechanism of AF in athletes, comprehensive haemodynamic studies are needed.[dx.doi.org]

Prevention

  • Loss of Rgs5 provoked dramatically exaggerated bradycardia and significantly (P CONCLUSION: The results of this study indicate that, as a critical regulator of parasympathetic activation in the heart, Rgs5 prevents vagal-related bradycardia and AT through[ncbi.nlm.nih.gov]
  • It appears that the correction of the acute metabolic derangements in this condition may not prevent rapid progression to death, suggesting that the rhythm disturbances in CACT deficiency result from prior and ongoing accumulation of toxic metabolites[ncbi.nlm.nih.gov]
  • Comparative effectiveness findings for stroke prevention were limited by the direct comparisons between individual direct oral anticoagulants.[effectivehealthcare.ahrq.gov]
  • This study found dabigatran is economically dominant versus rivaroxaban for prevention of stroke and systemic embolism among Canadian AF patients.[dx.doi.org]

References

Article

  1. Rodriguez LM, de Chillou C, Schläpfer J, et al. Age at onset and gender of patients with different types of supraventricular tachycardias. Am J Cardiol. 1992;70(13):1213–1215.
  2. Akhtar M, Jazayeri MR, Sra J, Blanck Z, Deshpande S, Dhala A. Atrioventricular nodal reentry. Clinical, electrophysiological, and therapeutic considerations. Circulation. 1993;88(1):282–295.
  3. Chauhan VS, Krahn AD, Klein GJ, Skanes AC, Yee R. Supraventricular tachycardia Med Clin North Am. 2001;85(2):193–223.
  4. Mark DG, Brady WJ, Pines JM. Preexcitation syndromes: diagnostic considerations in the ED. Am J Emerg Med. 2009;27(7):878–888.
  5. Wellens HJ, Brugada P. Mechanisms of supraventricular tachycardia. Am J Cardiol. 1988;62(6):10D–15D.
  6. Kastor JA. Multifocal atrial tachycardia. N Engl J Med. 1990;322(24):1713–1717.
  7. Roberts-Thomson KC, Kistler PM, Kalman JM. Focal atrial tachycardia II: management. Pacing Clin Electrophysiol. 2006;29(7):769–778.
  8. Lessmeier TJ, Gamperling D, Johnson-Liddon V, et al. Unrecognized paroxysmal supraventricular tachycardia. Potential for misdiagnosis as panic disorder. Arch Intern Med. 1997;157(5):537–543.
  9. Fenelon G, Wijns W, Andries E, Brugada P. Tachycardiomyopathy: mechanisms and clinical implications. Pacing Clin Electrophysiol. 1996;19(1):95–106

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Last updated: 2018-06-22 09:13