Supraventricular tachycardia

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Supraventricular tachycardia
Classification and external resources
SVT Lead II-2.JPG
Lead II electrocardiogram strip showing SVT with a heart rate of about 180.
ICD-10 I47.1
ICD-9 427.89, 427.0
MeSH D013617

Supraventricular tachycardia (SVT) is a condition[1][2] presenting as a rapid heart rhythm originating at or above the atrioventricular node. Supraventricular tachycardias can be contrasted with the potentially more dangerous ventricular tachycardias—rapid rhythms that originate within the ventricular tissue.

Although "SVT" can be due to any supraventricular cause, the term is most often used to refer to a specific example, paroxysmal supraventricular tachycardia (PSVT), two common types being atrioventricular reciprocating tachycardia and AV nodal reentrant tachycardia. In the older adult population atrial fibrillation becomes a common type of supraventricular arrhythmias—though it is typically considered separately.

In general, SVT is caused by one of two mechanisms: The first is re-entry; the second is automaticity. Re-entry (such as AV nodal reentrant tachycardia and atrioventricular reciprocating tachycardia) often presents with an almost immediate onset[3] with sudden increase in heart rate. A person experiencing this type of PSVT may feel the heart rate accelerate from 60 to 200 beats per minute or more. Typically, when it reverts to normal rhythm, this is also sudden.

impulse arising in SA node, traversing atria to AV node, then entering ventricle. Rhythm originating at or above AV node constitutes SVT.

The main pumping chamber, the ventricle, is protected (to a certain extent) against excessively high rates arising from the supraventricular areas by a 'gating mechanism' at the atrioventricular node, which allows only a proportion of the fast impulses to pass through to the ventricles. In a condition called Wolff-Parkinson-White Syndrome, a 'bypass tract' avoids this node and its protection and the fast rate may be directly transmitted to the ventricles. This situation has characteristic findings on ECG.

In automatic types of SVT (atrial tachycardia, junctional ectopic tachycardia), there is more typically a gradual increase and decrease in the heart rate. These are due to an area in the heart that generates its own electrical signal.

Types[edit]

atrial fibrillation. Irregular impulses reaching av node. Only some being transmitted.

The following types of supraventricular tachycardias are more precisely classified by their specific site of origin. While each belongs to the broad classification of SVT, the specific term/diagnosis is preferred when possible:

Sinoatrial origin:

  • Sinoatrial nodal reentrant tachycardia (SNRT)

Atrial origin:

(Without rapid ventricular response, fibrillation and flutter are usually not classified as SVT)

Atrioventricular origin (junctional tachycardia):

Signs and symptoms[edit]

Symptoms can arise suddenly and may resolve without treatment. Stress, exercise, and emotion can all result in a normal or physiological increase in heart rate, but can also, more rarely, precipitate SVT. Episodes can last from a few minutes to one or two days, sometimes persisting until treated. The rapid heart rate reduces the opportunity for the "pump" to fill between beats decreasing cardiac output and as a consequence blood pressure. The following symptoms are typical with a rate of 150–270 or more beats per minute:

For infants and toddlers, symptoms of heart arrhythmias such as SVT are more difficult to assess since infants cannot communicate these symptoms to others. Caregivers should watch for lack of interest in feeding, shallow breathing, and lethargy. These symptoms can be very understated and may be accompanied by vomiting and/or a decrease in responsiveness. [4]

Diagnosis[edit]

Holter monitor-Imaging with start (red arrow) and end (blue arrow) of a SV-tachycardia with a pulse frequency of about 128/min.
An 12 lead ECG showing supraventricular tachycardia at about 180 beats per min.

Individual subtypes of SVT can usually be distinguished by the electrical characteristics of the electrocardiogram (ECG).

Most supraventricular tachycardias have a narrow QRS complex, although, occasionally, electrical conduction abnormalities may produce a wide QRS complex that may mimic ventricular tachycardia (VT). In the clinical setting, the distinction between narrow and wide complex tachycardia (supraventricular vs. ventricular) is fundamental since they are treated differently. In addition, ventricular tachycardia can quickly degenerate to ventricular fibrillation and death and merits different consideration. In the less common situation in which a wide-complex tachycardia may actually be supraventricular, a number of algorithms have been devised to assist in distinguishing between them.[5] In general, a history of structural heart disease markedly increases the likelihood that the tachycardia is ventricular in origin.

  • Sinus tachycardia is physiologic or "appropriate" when a reasonable stimulus, such as the catecholamine surge associated with fright, stress, or physical activity, provokes the tachycardia. It is identical to a normal sinus rhythm except for its faster rate (>100 beats per minute in adults). In general, it is not considered SVT.
  • Sinoatrial node reentrant tachycardia (SANRT) is caused by a reentry circuit localised to the SA node, resulting in a P-wave of normal shape and size (morphology) that falls before a regular, narrow QRS complex. It cannot be distinguished electrocardiographically from sinus tachycardia unless the sudden onset is observed (or recorded on a continuous monitoring device). It may sometimes be distinguished by its prompt response to vagal manoeuvres.
  • Ectopic (unifocal) atrial tachycardia arises from an independent focus within the atria, distinguished by a consistent P-wave of abnormal morphology that falls before a narrow, regular QRS complex. It is caused by automaticity, which means that some cardiac muscle cells, which have the primordial ability to generate electrical impulses that is common to all cardiac muscle cells, have established themselves as a 'rhythm center' with a natural rate of electrical discharge that is faster than the normal SA node.
  • Multifocal atrial tachycardia (MAT) is tachycardia arising from at least three ectopic foci within the atria, distinguished by P-waves of at least three different morphologies that all fall before irregular, narrow QRS complexes.
    Atrial fibrillation. Red dots show atrial fibrillation activity
  • Atrial fibrillation is not, by itself, a tachycardia, but meets the definition when associated with a ventricular response greater than 100 beats per minute. It is characterized as an "irregularly irregular rhythm" both in its atrial and ventricular depolarizations and is distinguished by its fibrillatory atrial waves that, at some point in their chaos, stimulate a response from the ventricles in the form of irregular, narrow QRS complexes.
  • Atrial flutter, is caused by a re-entry rhythm in the atria, with a regular atrial rate often of about 300 beats per minute. On the ECG, this appears as a line of "sawtooth" waves preceding the QRS complex. The AV node will not usually conduct at such a fast rate, and so the P:QRS ratio is usually 2:1 or 4:1 pattern, (though rarely 3:1, and sometimes 1:1 where class IC antiarrhythmic drug are in use). Because the ratio of P to QRS is usually consistent, A-flutter is often regular in comparison to its irregular counterpart, A-fib. Atrial Flutter is also not necessarily a tachycardia unless the AV node permits a ventricular response greater than 100 beats per minute.
  • AV nodal reentrant tachycardia (AVNRT) involves a reentry circuit forming next to, or within, the AV node. The circuit most often involves two tiny pathways one faster than the other, within the AV node. Because the node is immediately between the atria and ventricle, the re-entry circuit often stimulates both, meaning that a retrogradely (backward) conducted P-wave is buried within or occurs just after the regular, narrow QRS complexes.
  • Atrioventricular reciprocating tachycardia (AVRT), also results from a reentry circuit, although one physically much larger than AVNRT. One portion of the circuit is usually the AV node, and the other, an abnormal accessory pathway (muscular connection) from the atria to the ventricle. Wolff-Parkinson-White syndrome is a relatively common abnormality with an accessory pathway, the Bundle of Kent crossing the AV valvular ring.
    • In orthodromic AVRT, atrial impulses are conducted down through the AV node and retrogradely re-enter the atrium via the accessory pathway. A distinguishing characteristic of orthodromic AVRT can therefore be a P-wave that follows each of its regular, narrow QRS complexes, due to retrograde conduction.
    • In antidromic AVRT, atrial impulses are conducted down through the accessory pathway and re-enter the atrium retrogradely via the AV node. Because the accessory pathway initiates conduction in the ventricles outside of the bundle of His, the QRS complex in antidromic AVRT is often wider than usual, with a delta wave.
  • Finally, junctional ectopic tachycardia (JET) is a rare tachycardia caused by increased automaticity of the AV node itself initiating frequent heart beats. On the ECG, junctional tachycardia often presents with abnormal morphology P-waves that may fall anywhere in relation to a regular, narrow QRS complex. It is often due to drug toxicity.

Treatment[edit]

Most SVTs are unpleasant rather than life-threatening, although very fast heart rates can be problematic for those with underlying ischemic heart disease or the elderly. Episodes require treatment when they occur, but interval therapy may also be used to prevent or reduce recurrence. While some treatment modalities can be applied to all SVTs, there are specific therapies available to treat some sub-types. Effective treatment consequently requires knowledge of how and where the arrhythmia is initiated and how it is spread.

SVTs can be classified by whether the AV node is involved in maintaining the rhythm. If so, slowing conduction through the AV node will terminate it. If not, AV nodal blocking maneuvers will not work, although transient AV block is still useful as it may unmask an underlying abnormal rhythm.

AV nodal blocking can be achieved in at least three ways:

Physical maneuvers[edit]

A number of physical maneuvers increase AV nodal block, principally through activation of the parasympathetic nervous system, conducted to the heart by the vagus nerve. These manipulations are collectively referred to as vagal maneuvers.

The Valsalva maneuver should be the first vagal maneuver tried[6] and works by increasing intra-thoracic pressure and affecting baroreceptors (pressure sensors) within the arch of the aorta. It is carried out by asking the patient to hold his/her breath and try to exhale forcibly as if straining during a bowel movement. Holding the nose and exhaling against the obstruction has a similar effect.[7]

Lying on your back with your legs vertical (normally against a wall) and relaxing with slow steady breaths may end the episode.

There are other vagal maneuvers including: holding one's breath for a few seconds, coughing, plunging the face into cold water,[7] (via the diving reflex[8]), drinking a glass of ice cold water, and standing on one's head. Carotid sinus massage, carried out by firmly pressing the bulb at the top of one of the carotid arteries in the neck, is effective but is often not recommended in the elderly due to the potential risk of stroke in those with atherosclerotic plaque in the carotid arteries.

Reducing coffee, alcohol, or tobacco use or increasing the amount of rest may help to alleviate symptoms. Pressing down gently on the top of closed eyes may also bring heartbeat back to normal rhythm for some people suffering from atrial or supraventricular tachycardia (SVT).[9]

Medications[edit]

Termination of PSVT following adenosine

Adenosine, an ultra-short-acting AV nodal blocking agent, is indicated if vagal maneuvers are not effective.[10] If successful, followup therapy with diltiazem, verapamil or metoprolol may be indicated. Adenosine may be safely used during pregnancy.[11]

SVT that does not involve the AV node may respond to other anti-arrhythmic drugs such as sotalol or amiodarone.

Cardioversion[edit]

If the patient is unstable or other treatments have not been effective, synchronized electrical cardioversion may be used.

Prevention[edit]

Once an acute arrhythmia has been terminated, ongoing treatment may be indicated to prevent recurrence. However, those that have an isolated episode, or infrequent and minimally symptomatic episodes, usually do not warrant any treatment other than observation.

In general, patients with more frequent or disabling symptoms warrant some form of prevention. A variety of drugs including simple AV nodal blocking agents such as beta-blockers and verapamil, as well as anti-arrhythmics may be used, usually with good effect, although the risks of these therapies need to be weighed against potential benefits.

Radiofrequency ablation has revolutionized the treatment of tachycardia caused by a re-entrant pathway. This is a low-risk procedure that uses a catheter inside the heart to deliver radio frequency energy to locate and destroy the abnormal electrical pathways. Ablation has been shown to be highly effective: around 90% in the case of AVNRT. Similar high rates of success are achieved with AVRT and typical Atrial Flutter.

There is a newer treatment for SVT involving the AV node directly. This treatment is called Cryoablation. SVT involving the AV node is often a contraindication for using radiofrequency ablation due to the small (1%) incidence of injuring the AV node, requiring a permanent pacemaker. With Cryoablation, a supercooled catheter is used (cooled by nitrous oxide gas), and the tissue is frozen to −10 °C. This provides the same result as radiofrequency ablation but does not carry the same risk. If you freeze the tissue and then realize you are in a dangerous spot, you can halt freezing the tissue and allow the tissue to spontaneously rewarm and the tissue is the same as if you never touched it. If after freezing the tissue to −10 °C, you get the desired result, then you freeze the tissue down to a temperature of −73 °C and you permanently ablate the tissue.

This therapy has further improved the treatment options for people with AVNRT (and other SVTs with pathways close to the AV node), widening the application of curative ablation to young patients with relatively mild but still troublesome symptoms who would not have accepted the risk of requiring a pacemaker.

Notable cases[edit]

Rebecca Soni, Olympic champion swimmer
Nathan Cohen, rowing world and Olympic champion

After being successfully diagnosed and treated, Bobby Julich went on to place third in the 1998 Tour de France and win a Bronze Medal in the 2004 Summer Olympics. Women's Olympic volleyball player Tayyiba Haneef-Park underwent an ablation for SVT just two months before competing in the 2008 Summer Olympics.[12] Tony Blair, former PM of the UK, was also operated on for atrial flutter. Anastacia was diagnosed with the disease.[13] Women's Olympic gold medalist swimmers, Rebecca Soni and Dana Vollmer have both had heart surgery to correct SVT. In addition, Neville Fields had corrective surgery for SVT in early 2006. Wrestling manager Paul Bearer's heart attack was attributed to SVT, resulting in his death.[14] Nathan Cohen, New Zealand's two-time world champion and Olympic champion rower, was diagnosed with SVT in 2013 when he was 27 years old.[15][16][17]

See also[edit]

References[edit]

  1. ^ David D. Weaver. Catalog of Prenatally Diagnosed Conditions. Retrieved 2013-11-02. 
  2. ^ "What is Blair's heart condition?". Dailymail.co.uk. 2004-10-01. Retrieved 2013-11-02. 
  3. ^ "paroxysmal supraventricular tachycardia" at Dorland's Medical Dictionary
  4. ^ Iyer, V. Ramesh, MD, MRCP. "Supraventricular Tachycardia". Children's Hospital of Philadelphia. Retrieved June 8, 2014. 
  5. ^ Lau EW, Ng GA (2002). "Comparison of the performance of three diagnostic algorithms for regular broad complex tachycardia in practical application". Pacing and clinical electrophysiology : PACE 25 (5): 822–7. doi:10.1046/j.1460-9592.2002.00822.x. PMID 12049375. 
  6. ^ "BestBets: Comparing Valsalva manoeuvre with carotid sinus massage in adults with supraventricular tachycardia". 
  7. ^ a b Vibhuti N, Singh; Monika Gugneja (2005-08-22). "Supraventricular Tachycardia". eMedicineHealth.com. Retrieved 2008-11-28. 
  8. ^ Mathew PK (January 1981). "Diving reflex. Another method of treating paroxysmal supraventricular tachycardia". Arch. Intern. Med. 141 (1): 22–3. doi:10.1001/archinte.141.1.22. PMID 7447580. 
  9. ^ "Tachycardia | Fast Heart Rate". American Heart Association. Retrieved 19 April 2013. 
  10. ^ "Adenosine vs Verapamil (calcium channel blocker) in the acute treatment of supraventricular tachycardias". 
  11. ^ Blomström-Lundqvist ET AL., MANAGEMENT OF PATIENTS WITH Supraventricular Arrhythmias. J Am Coll Cardiol 2003;42:1493–531 [1]
  12. ^ "USA Volleyball 2008 Olympic Games Press Kit". Usavolleyball.org. Retrieved 2013-11-02. 
  13. ^ "Anastacia delays heart surgery". News of the World. 3 Nov 2008. Retrieved 30 Apr 2010. 
  14. ^ "Paul Bearer Cause of Death – Heart Attack". TMZ.com. 2013-03-23. Retrieved 2013-11-02. 
  15. ^ Ian Anderson (27 August 2013). "Rowing | Bad day for New Zealand crews". Stuff.co.nz. Retrieved 30 October 2013. 
  16. ^ "Heart problems force Olympic champion out of world champs". Radio New Zealand. 26 August 2013. Retrieved 30 October 2013. 
  17. ^ "Heart trouble rules Cohen out of rowing World Champs". TVNZ. 26 August 2013. Retrieved 30 October 2013.  Scott Brady of punk band Brave The Wild (https://www.facebook.com/BraveTheWild) suffers from this. He had his first attack on April 9, 2012 while golfing and was hospitalized over night. He was diagnosed April 17, 2014 in Hamilton ON after having an attack walking home from dinner on Mach 16, 2014.

External links[edit]

Movie/Animation of SVT: Video section: The University of Iowa Children's Hospital