TACHYCARDIAS

By Aly Amer
TACHYCARDIAS CLASSIFICATION
INTRODUCTION

Regular narrow QRS tachycardias (Less than or equal to 120 ms)

• Sinus tachycardia
• Atrial flutter with 2:1 atrioventicular (AV) block
• Atrioventricular nodal re-entrant tachycardia (AVNRT)
• Some types of atrioventricular re-entrant tachycardia (AVRT)
• Focal and multifocal atrial tachycardia

Irregular narrow QRS tachycardias (Less than or equal to 120 ms)

• Atrial fibrillation (AF)

• Focal atrial tachycardia or atrial flutter with variable degrees of AV block (for example 2:1 or 3:1)
• Multifocal atrial tachycardia
Regular wide QRS tachycardias (Greater than 120 ms)

• Monomorphic ventricular tachycardia (VT)

• Supraventricular tachycardia (SVT) with aberrant conduction
• Pre-excited (antidromic) atrioventricular re-entrant tachycardia (AVRT)

Irregular wide QRS tachycardias (Greater than 120 ms)

• Polymorphic ventricular tachycardia, for example Torsades de point

• Ventricular fibrillation
• atrial fibrillation (AF) with aberrant conduction
 NARROW QRS TACHYCARDIAS: SINUS TACHYCARDIA
• Sinus rhythm means that the sinoatrial (SA) node is generating P waves. Normal sinus rhythm can be
defined electrocardiographically as the presence of a morphologically normal P wave before each QRS
complex , with a consistent timing interval or PR interval. Morphologically normal P waves will be upright
in lead II, and inverted in lead aVR.
• Sinus tachycardia is defined in adults as sinus rhythm, with a heart rate of more than 100 beats per minute,
when the patient is resting. Sinus tachycardia rarely exceeds 200 beats per minute .
A focal atrial tachycardia
is an abnormal narrow complex tachycardia of more than 100 beats per minute.
It arises from an ectopic source within the atrial myocardium, in comparison with sinus rhythm which arises from the
SA node. Analysis of the P wave morphology can help predict the origin of an atrial tachycardia.
Learning points
• Atrial tachycardia and AV nodal block
• Confusion between atrial tachycardia and sinus tachycardia
• Atrial tachycardia resembling atrial flutter
Atrioventricular re-entrant tachycardias (AVRTs)
In AVRTs, one limb of the re-entry circuit involves an accessory pathway that is outside of
the AV node (and one limb of the re-entry circuit involves the AV node)
Atrioventricular nodal re-entrant tachycardias (AVNRTs)
•In AVNRTs, the re-entry circuit is confined to the tissue immediately proximal to the AV node (also known as a
dual AV nodal pathways).
Wide QRS tachycardia
There are several different types and origins of wide QRS tachycardia including :

• Ventricular tachycardia: this should be the default diagnosis until proven otherwise
• Supraventricular tachycardias such as atrial tachycardia, AVNRT, and AVRT with aberrant conduction
(for example in bundle branch block)
• Supraventricular tachycardias (such as atrial tachycardia, AVNRT, and AVRT) conducted through an
accessory pathway
•Supraventricular tachycardias with widening of the QRS interval induced by drugs or electrolyte
disturbances
•Paced rhythms
•Artefact.
Ventricular
Tachycardia
Supraventricular tachycardia with aberrant conduction
ECG features increasing the likelihood of VT

Absence of typical RBBB or LBBB morphology

Extreme axis deviation (“northwest axis”): QRS positive in aVR and negative in I and aVF
Very broad complexes > 160ms
AV dissociation:
P and QRS complexes at different rates
P waves are often superimposed on QRS complexes and may be difficult to discern
Capture beats: Occur when the sinoatrial node transiently “captures” the ventricles in the midst of AV dissociation, producing a
QRS complex of normal duration
Fusion beats: Occur when a sinus and ventricular beat coincide to produce a hybrid complex (see Dressler beat)
Capture Beat Fusion Beat VT ECG waves
 concordance
Positive concordance Negative concordance
Atrial fibrillation
The pathophysiology of atrial fibrillation involves complex electrophysiological changes from an ectopic focus, or
from firing of a single or multiple re-entry circuits.

• No P wave activity

• Irregularly irregular ventricular rate

Atrial Flutter
• Atrial flutter is a narrow QRS tachycardia identified on the ECG by flutter waves, which produce a sawtooth
pattern of atrial activation.
• Atrial flutter is characterised by regular atrial activity at around 300 beats per minute. Usually the ventricles will
only conduct at around half this rate . This is also known as 2:1 AV block .
• Some patients with atrial flutter have 3:1 or 4:1 AV block, for example, those taking drugs such as beta blockers
Multifocal Atrial Tachycardia
•A rapid, irregular atrial rhythm arising from multiple ectopic foci within the atria.
•Most commonly seen in patients with severe COPD or congestive heart failure.
•It is typically a transitional rhythm between frequent premature atrial complexes (PACs) and atrial flutter /
fibrillation.
•Heart rate > 100 bpm (usually 100-150 bpm; may be as high as 250 bpm).
•Irregularly irregular rhythm with varying PP, PR and RR intervals.
•At least 3 distinct P-wave morphologies in the same lead.
Polymorphic ventricular tachycardia, for example Torsades de point

is a specific form of PVT occurring in the context of QT prolongation — it has a characteristic morphology in which
the QRS complexes “twist” around the isoelectric line.
is a form of ventricular tachycardia in which there are multiple ventricular foci with the resultant QRS complex
varying in amplitude, axis, and duration
atrial fibrillation (AF) with aberrant conduction
CASES
Thank you
Atrial tachy
AVNRT
orthodromic AVRT
antidromic AVRT
Slow VT
SVT abberant
VT
AF
Aflutter
MAT