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SVT Presentation
SVT Presentation
SVT Presentation
Tachycardia
Teresa Menendez Hood, MD FACC
Presbyterian Hospital of Dallas
Supraventricular Tachycardias
• AV nodal reentry tachycardia
• AV reentry tachycardia - the WPW(Wolff-Parkinson White) Syndrome
• Atrial flutter
• Atrial Fibrillation
• Atrial Tachycardia
• Sinus Tachycardia and Sinus Node Reentry
Atrial Fibrillation
• Unorganized, very rapid electrical foci in the atria
• No contraction of the atria as a whole
• In order to protect the ventricles, the AV node
blocks most of the atrial impulses from conducting
through to the ventricles, thus protecting the
ventricles
• Controlled rate = ventricular rate < 100 beats/min
• Uncontrolled rate = ventricular rate > 100
beats/min
Atrial Fibrillation
9% 34%
SSS Atrial
Fibrillation
8%
Conduction
Disease 10% VT
3% SCD
2% VF
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Risk Factors for Stroke in AF
Risk Factor Relative Risk (multivariate)
Prior stroke 2.5
Age 1.4 (per decade)
Hypertension 1.6
Diabetes 1.7
Absolute Risk
Age < 65 years and no risk factors, “lone AF”: 1%/yr.
All others: 3.5%-8+%/yr lowered to ~1.5%/yr by warfarin
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Elective Cardioversion of AF
Anticoagulation
• Cardioversion appears to raise risk of embolism
– 1%-5% emboli within hours to weeks
– Anticoagulation well before and after greatly
reduces risk
• Standard guideline for electrical or drug cardioversion
– INR 2 - 3 for 3 weeks before; and
– INR 2 - 3 for 4 weeks after NSR
– IF AF < 2 days’ duration, no anticoagulation
A HB B
RB LB
C D
Akhtar M. In:Zipes and Jalife. Cardiac Electrophysiology from Cell to Bedside. 1990:636.
Key ECG Signs
• Atrial activity
• QRS configuration
• R-R cycle length
• Aberrant ventricular conduction
• Response to vagal maneuvers
An EKG you will see on the
Boards………..
• Characteristics:
– Rhythm is regular
– Rate 140-220 beats/minute
– P waves may be buried in the QRS or the T wave
and may differ in morphology from sinus P waves
– PR and QRS interval may be normal or prolonged.
Supraventricular Tachycardia
– Long term treatment is with ablation in most cases
– Response to vagal maneuvers is helpful
– Acutely: meds used to decrease the rate or convert the
patient to NORMAL SINUS RHYTHM: Adenosine, IV
Verapamil or Esmolol
– If patient is unstable:
• Electrical cardioversion
Pearls
• ST depression is common during SVT and is not a
marker of serious ischemia
• If the first dose of Adenosine does not work? Then
add 6mg to the amount and give again (6-12-18)…
do not repeat the same dose. (If given via central
line then 3-6-9-12)
• Adenosine may put the patient in AFB…be ready
to cardiovert.
Classification of PSVT
• Short R-P
– AVRT(slow-fast)
– AVNRT
• Long R-P
– Atypical forms of the AVNRT (fast-slow)or
AVRT(usually will have a negative P wave in 2,3,avf)
– Most atrial tachycardias, SNRT
– PJRT
Atrial Tachycardia
• Reentry, Automaticity and Triggered (rare) Activity
have been found as causes
• Rates 120 to 150
• Usually 1:1 AVN conduction and persistence despite
AV block
• Usually from right atria (Ring of Fire)
• Can be seen as an incisional tachycardia from previous
surgery..i.e. ASD repair
• May see remission in children so do not attempt
ablation until adulthood.
AVN reentry
• Most common from of PSVT
• Can occur at any age and more common in women
• Typical form is down the slow and up the fast
pathway in the AVN region.
• Adenosine is the drug on choice for conversion.
Need to be careful about pts with reactive airway
disease and those on persantine. It may not work
in pts with theophylline.
WPW
• Pre-excitation affects 3/1000 patients on
routine screening….not all develop PSVT
• Antegrade (delta wave) and retrograde
conduction
• More common in men
• Most present in young adulthood
• 15% incidence of AFIB
• Multiple pathways in 10%