Narrow Complex Tachycardia

Aka: Narrow Complex Tachycardia, Supraventricular Tachycardia, Paroxysmal Supraventricular Tachycardia, PSVT

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II. Definition

  1. Rapid heart rhythms originating in the atrium or atrioventricular node
  2. Transmit via the bundle of His and result in rapid ventricular response

III. Epidemiology

  1. Prevalence: 2-3 per 1000 persons (U.S.)
  2. Age (mean): 45 years old
  3. Gender: Women represent 62% of cases

IV. Causes: Narrow Complex Tachycardia (Mnemonic: 5H 5T PS)

  1. Similar list to Reversible Causes of Cardiopulmonary Arrest (5H5T)
  2. Hypoxemia
  3. Hypovolemia
  4. Hyperthermia
  5. Hyperkalemia
  6. Hypokalemia
  7. Tamponade (Cardiac Tamponade)
  8. Tension Pneumothorax
  9. Toxins, medications and drugs
    1. Caffeine
    2. Tobacco
    3. Alcohol
    4. Pseudophedrine (or other Sympathomimetics)
  10. Thrombus
    1. Myocardial Infarction
    2. Pulmonary Embolism
  11. Pain or Stress
  12. Structural abnormalities (especially in children)
    1. Hypertrophic Cardiomyopathy
    2. Congenital Heart Disease

V. Types: Narrow Complex Tachycardia

  1. Sinus Tachycardia
  2. Supraventricular Tachycardia
    1. Atrioventricular Nodal Reentry (AVNRT)
      1. Signal down the slow AV nodal pathway and retrograde up the fast AV nodal pathway
      2. In 10% of cases, the signal reentry route is reversed
    2. Atrioventricular Reciprocating Tachycardia (AVRT)
      1. Includes Wolff-Parkinson-White Syndrome (characterized by delta wave)
      2. Accessory pathway outside the AV node
        1. Orthodromic (narrow complex): Signal down the AV node and up the accessory path
        2. Antidromic (wide complex): Signal down the accessory path and up the AV node
    3. Atrial Tachycardia (AT)
      1. Abnormal focus of atrial automaticity (outside the SA node)
      2. Unlike AVNRT and AVRT, no accessory pathway is involved
  3. Other Atrial Tachycardias with rapid ventricular response
    1. Atrial Fibrillation
    2. Atrial Flutter

VI. Differential Diagnosis: Adults - Narrow Complex Tachycardia (key question is 'regular or irregular')

  1. Sinus Tachycardia (regular)
  2. Irregular Supraventricular Tachycardia (may also present as wide complex if aberrancy)
    1. Atrial Fibrillation
  3. Regular Supraventricular Tachycardia
    1. Atrial Flutter
    2. Atrioventricular Nodal Reentry (AVNRT): 60% of SVT cases (esp. women)
    3. Atrioventricular Reciprocating Tachycardia (AVRT): 30% of SVT cases
    4. Atrial Tachycardia (AT): 10% of SVT cases

VII. Differential Diagnosis: Children - Narrow Complex Tachycardia

  1. Common
    1. Orthodromic Atrioventricular Reciprocating Tachycardia (Orthodromic AVRT, or ORT)
      1. Most common in children (typical, narrow complex SVT)
    2. Atrioventricular Nodal Reentry (AVNRT)
      1. Second most common SVT in children (but rare in young children)
  2. Uncommon
    1. Ectopic Atrial Tachycardia
      1. Similar to sinus rhythm except for altered P Wave appearance and more rapid rate
    2. Atrial Flutter (uncommon in children outside the newborn period)
    3. Atrial Fibrillation (very rare in children)
  3. Congenital Heart Disease history
    1. CHD predisposes patients to scarring with risk of reentrant pathways
    2. Intra-atrial reentrant Tachycardia (IART)
      1. Appears similar to Atrial Flutter
      2. Typically treated with rate control on Diltiazem (if over age 2-5 years), followed by cardioversion

VIII. History

  1. Timing
    1. Rapid onset and resolution
      1. Supraventricular Tachycardia
    2. Slow onset and resolution
      1. Sinus Tachycardia
  2. Precipitating factors
    1. Caffeine or stimulants, stress
      1. Supraventricular Tachycardia or Sinus Tachycardia
    2. Cardiovascular disease or onset with activity
      1. Ventricular Tachycardia

IX. Symptoms: Episodic

  1. Anxiety
  2. Chest pressure
  3. Dyspnea
  4. Fatigue
  5. Light headed
  6. Palpitations

X. Signs: Electrocardiogram

  1. Sinus Tachycardia
    1. P Waves present and normal
      1. At higher rates P Wave may be hidden in T Wave
      2. Look for high frequency notching within the T Wave to suggest a hidden P Wave
    2. Variable R-R with constant PR interval
    3. Heart Rate varies with activity
    4. Rate lower than PSVT
      1. Infants < 220 (may approach this with fever)
      2. Children < 180
      3. Adults < 160
  2. Supraventricular Tachycardia
    1. P Waves absent or abnormal
    2. Fixed Heart Rate (constant R-R)
    3. Abrupt rate change
    4. Rate higher than Sinus Tachycardia (especially if Heart Rate twice normal for age or higher)
      1. Infants > 220
      2. Children > 180
      3. Adults > 160

XI. Labs

  1. Thyroid Stimulating Hormone (TSH)
  2. Basic metabolic panel
  3. Complete Blood Count
  4. Chest XRay
  5. Additional tests to consider (in adults)
    1. Brain Natriuretic Peptide (ntBNP)
    2. Troponin
    3. Holter Monitor or Event Monitor
    4. Echocardiogram

XII. Management: Stable Patients

  1. New emphasis on use of one Antiarrhythmic
    1. Contrast to prior Antiarrhythmic soups
    2. Pro-arrhythmic effects increase with poly-drugs
  2. Supraventricular Tachycardia Management in the Adult
  3. Supraventricular Tachycardia Management in the Child

XIII. Management: Unstable Patients

  1. See Unstable Tachycardia

XIV. Management: Cardiology Consultation Indications

  1. Uncertain diagnosis or management
  2. Recurrent Supraventricular Tachycardia refractory to medications
  3. High risk profession or activity (e.g. truck driver, airline pilot, rock climbing, Scuba Diving)
  4. Ablation considered over medication (patient preference)
  5. Wolff-Parkinson-White Syndrome (characterized by delta wave)
  6. Structural heart disease (e.g. Hypertrophic Cardiomyopathy)
  7. Syncope associated with Supraventricular Tachycardia
  8. Wide complex on EKG

XV. References

  1. Claudius, Behar and Bar Cohen in Herbert (2014) EM:Rap 14(5):1-2
  2. Hebbar (2002) Am Fam Physician 65(12):2479-86 [PubMed]
  3. Helton (2015) Am Fam Physician 92(9): 793-800 [PubMed]
  4. Cardiopulmonary Resuscitation Guidelines
    1. http://www.circulationaha.org
    2. (2010) Guidelines for CPR and ECC [PubMed]
    3. (2005) Circulation 112(Suppl 112):IV [PubMed]
    4. (2000) Circulation, 102(Suppl I):86-9 [PubMed]

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Ontology: Paroxysmal supraventricular tachycardia (C0030590)

Definition (CHV) periods of very rapid heart beats that begin and end abruptly
Definition (CHV) periods of very rapid heart beats that begin and end abruptly
Definition (NCI) An electrocardiographic finding of episodic supraventricular tachycardia with abrupt onset and termination.
Concepts Disease or Syndrome (T047)
ICD9 427.0
SnomedCT 195074009, 266305002, 155363003, 67198005
English Paroxysm.supravent.tachyc. NOS, Paroxysmal supravent.tachycard, Paroxysmal supraventricular tachycardia NOS, PSVT, paroxysmal supraventricular tachycardia (diagnosis), paroxysmal supraventricular tachycardia, Paroxysmal tachycardia (supraventricular), Parox atrial tachycardia, paroxysmal supraventricular tachycardia (PSVT), psvt, Paroxysmal supraventricular tachycardia NOS (disorder), Paroxysmal sup. tachy., Tachycardia - parox.sup, Supravent. tach. parox., Paroxysmal Supraventricular Tachycardia by ECG Finding, Paroxysmal Supraventricular Tachycardia by EKG Finding, Paroxysmal Supraventricular Tachycardia, Paroxysmal supraventricular tachycardia (disorder), paroxysmal; tachycardia, supraventricular, tachycardia; paroxysmal, supraventricular, Paroxysmal supraventricular tachycardia, Tachycardia;supraventr;paroxys
Dutch paroxysmale supraventriculaire tachycardie, paroxysmale tachycardie (supraventriculair), paroxysmaal; tachycardie, supraventriculair, tachycardie; paroxysmaal, supraventriculair
French Tachycardie paroxystique supraventriculaire, Tachycardie paroxystique (supraventriculaire)
German paroxysmale supraventrikulaere Tachykardie, paroxysmale Tachykardie (supraventrikulaer)
Italian Tachicardia parossistica (sopraventricolare), Tachicardia parossistica sopraventricolare
Portuguese Taquicardia supraventricular paroxística
Spanish Taquicardia supraventricular paroxística, Taquicardia paroxística (supraventricular), taquicardia paroxística supraventricular, SAI (trastorno), taquicardia paroxística supraventricular, SAI, taquicardia supraventricular paroxística (trastorno), taquicardia supraventricular paroxística
Japanese 発作性頻脈（上室性）, 発作性上室性頻脈, ﾎｯｻｾｲﾋﾝﾐｬｸｼﾞｮｳｼﾂｾｲ, ﾎｯｻｾｲｼﾞｮｳｼﾂｾｲﾋﾝﾐｬｸ
Czech Paroxysmální tachykardie (supraventrikulární), Paroxysmální supraventrikulární tachykardie
Hungarian Paroxysmalis supraventricularis tachycardia, Paroxysmalis tachycardia (supraventricularis)
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Supraventricular tachycardia (C0039240)

Definition (NCI) A disorder characterized by an electrocardiographic finding of a tachycardia which does not originate in the ventricles or His Purkinje system. There is an abnormally high heart rate and QRS complexes are typically narrow, but aberration or preexcitation may be present. (CDISC)
Definition (NCI_CTCAE) A disorder characterized by a dysrhythmia with a heart rate greater than 100 beats per minute that originates above the ventricles.
Definition (MSH) A generic expression for any tachycardia that originates above the BUNDLE OF HIS.
Concepts Disease or Syndrome (T047)
MSH D013617
ICD10 I47.1
SnomedCT 195104006, 266305002, 155363003, 6456007
LNC LA17100-1
English Supraventricular Tachycardias, Tachycardia, Supraventricular, Tachycardias, Supraventricular, SVT, TACHYCARDIA SUPRAVENTRICULAR, Supraventric. tachycardia NOS, Supraventricular tachycardia NOS, SVT - Supraventricular tachy, supraventricular tachycardia (diagnosis), supraventricular tachycardia, Tachycardia supraventricular, Tachycardia, Supraventricular [Disease/Finding], tachycardia supraventricular, supraventricular tachycardias, Supraventricular tachycardia (SVtach), Supraventricular tachycardia NOS (disorder), SVT - Supraventricular tachycardia, Supraventricular tachycardia (disorder), supraventricular; tachycardia, tachycardia; supraventricular, Supraventricular tachycardia, NOS, Supraventricular tachycardia, Supraventricular Tachycardia
French TACHYCARDIE SUPRAVENTRICULAIRE, TSV, Tachycardie supraventriculaire, Tachycardie supra-ventriculaire
Portuguese TAQUICARDIA SUPRAVENTRICULAR, Taquicardia supraventricular, Taquicardia Supraventricular
Spanish TAQUICARDIA SUPRAVENTRICULAR, TSV, taquicardia supraventricular, SAI (trastorno), taquicardia supraventricular, SAI, taquicardia supraventricular (trastorno), taquicardia supraventricular, Taquicardia supraventricular, Taquicardia Supraventricular
Dutch tachycardie supraventriculair, SVT, supraventriculair; tachycardie, tachycardie; supraventriculair, supraventriculaire tachycardie, Supraventriculaire tachycardie, Tachycardie, supraventriculaire
German SVT, Supraventrikulaere Tachykardie, TACHYKARDIE SUPRAVENTRIKULAER, Tachykardie supraventrikulaer, Supraventrikuläre Tachykardie, Tachykardie, supraventrikuläre
Japanese 上室性頻脈, ｼﾞｮｳｼﾂｾｲﾋﾝﾐｬｸ
Swedish Takykardi, supraventrikulär
Finnish Supraventrikulaarinen takykardia
Russian TAKHIKARDIIA SUPRAVENTRIKULIARNAIA, TAKHIKARDIIA NADZHELUDOCHKOVAIA, ТАХИКАРДИЯ НАДЖЕЛУДОЧКОВАЯ, ТАХИКАРДИЯ СУПРАВЕНТРИКУЛЯРНАЯ
Czech SVT, Tachykardie supraventrikulární, Supraventrikulární tachykardie, supraventrikulární tachykardie, tachykardie supraventrikulární, supraventrikulární tachyarytmie
Korean 심실상성 빠른맥
Polish Svt, Tachykardia nadkomorowa, Częstoskurcz nadkomorowy
Hungarian SVT, Tachycardia, supraventricularis, Supraventricularis tachycardia
Norwegian Supraventrikulær takykardi
Italian Tachicardia sopraventricolare
Derived from the NIH UMLS (Unified Medical Language System)

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