AVNRT

Atrioventricular Nodal
Reentrant Tachycardia
• The term supraventricular tachycardia (SVT), whilst often used
synonymously with AV nodal re-entry tachycardia (AVNRT), can be
used to refer to any tachydysrhythmia arising from above the level of
the Bundle of His
• The tachycardia typically ranges between 140-280 bpm and is regular
in nature.  It may cease spontaneously (and abruptly) or continue
indefinitely until medical treatment is sought.
• The condition is generally well tolerated and is rarely life threatening
in patients with pre-existing heart disease.
• AVNRT is typically paroxysmal and may occur spontaneously or upon
provocation with exertion, caffeine, alcohol, beta-agonists
(salbutamol) or sympathomimetics (amphetamines).
• It is more common in women than men (~ 75% of cases occurring in
women) and may occur in young and healthy patients as well as those
suffering chronic heart disease.
• In AVNRT, there are two pathways within the AV node:
• The slow pathway (alpha):  a slowly-conducting pathway with a short
refractory period.
• The fast pathway (beta):  a rapidly-conducting pathway with a long
refractory period.
Patogenesis
• During sinus rhythm, electrical impulses travel down both pathways
simultaneously. The impulse transmitted down the fast pathway enters the distal
end of the slow pathway and the two impulses cancel each other out.
• However, if a premature atrial contraction (PAC) arrives while the fast pathway is
still refractory, the electrical impulse will be directed solely down the slow pathway
(1).
• By the time the premature impulse reaches the end of the slow pathway, the fast
pathway is no longer refractory (2) — hence the impulse is permitted to recycle
retrogradely up the fast pathway.
• This creates a circus movement whereby the impulse continually cycles around the
two pathways, activating the Bundle of His anterogradely and the atria retrogradely
(3). The short cycle length is responsible for the rapid heart rate.
• This is the most common type of re-entrant circuit and is termed Slow-Fast AVNRT.
• Similar mechanisms exist for the other types of AVNRT.
EKG (general)
• Regular tachycardia  ~140-280 bpm.
• QRS complexes usually  narrow (< 120 ms)
• ST-segment depression may be seen with or without underlying
coronary artery disease.
• QRS alternans – phasic variation in QRS amplitude associated with
AVNRT and AVRT, distinguished from electrical alternans by a normal
QRS amplitude.
• P waves may be buried in the QRS complex, visible after the QRS
complex, or very rarely visible before the QRS complex.
EKG (slow-fast)

• Accounts for 80-90% of AVNRT

• Associated with Slow AV nodal pathway for anterograde conduction
and Fast AV nodal pathway for retrograde conduction.
• The retrograde P wave is obscured in the corresponding QRS or occurs
at the end of the QRS complex as pseudo r’ or S waves
Cardiac rhythm strips demonstrating (top) sinus rhythm and (bottom) paroxysmal SVT. The P
wave is seen as a pseudo-R wave (circled in bottom strip) in lead V1 during tachycardia. By
contrast, the pseudo-R wave is not seen during sinus rhythm (it is absent from circled area in
top strip). This very short ventriculo-atrial time is frequently seen in typical Slow-Fast AVNRT.
Terapi
• Patients may be instructed to undertake vagal manoeuvres upon the onset of
symptoms which can be effective in stopping the AVNRT.  This may involve carotid
sinus massage or valsalva manoeuvres, which will both stimulate the vagus nerve. 
• Adenosine, beta-blockers or calcium channel blockers can suppress an AVNRT event
by blocking or slowing the AV node.  Other second-line therapies may include
amiodarone or flecainide.
• Cardioversion is rarely used on patients with AVNRT, usually when the tachycardia is
refractory to other medical therapies or the tachycardia is causing haemodynamic
instability (falling blood pressure, development of heart failure etc.)
• Radiofrequency catheter ablation can be offered to patients with frequent attacks for
whom medical therapy isn’t appropriate in the long term, and can be curative.
Sumber
• https://lifeinthefastlane.com/ecg-library/svt/
• Patophysiology Lilly
• PAC terjadi ketika daerah lain dari atrium mendepolarisasi sebelum
node sinoatrial dan dengan demikian memicu detak jantung dini.