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Tachyarrhythmia: Pearls for ECG Diagnosis

Tachyarrhythmia: Pearls for ECG Diagnosis. Arjun V. Gururaj, MD Cardiac Arrhythmia and EP Nevada Heart and Vascular Center. Initial Evaluation. Hemodynamic stability History of CAD or previous MI History of syncope Depressed LV function Baseline ECG Characteristics of the tachycardia

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Tachyarrhythmia: Pearls for ECG Diagnosis

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  1. Tachyarrhythmia: Pearls for ECG Diagnosis Arjun V. Gururaj, MD Cardiac Arrhythmia and EP Nevada Heart and Vascular Center

  2. Initial Evaluation • Hemodynamic stability • History of CAD or previous MI • History of syncope • Depressed LV function • Baseline ECG • Characteristics of the tachycardia • Narrow complex • Wide complex • Other morphologic clues

  3. Should you use electrical therapy? • Acute hemodynamic collapse • Acute cardiac ischemia or infarction • Tachycardia induced congestive heart failure • Beware atrial fibrillation (CVA risk) • Follow ACLS protocols in most cases

  4. What’s the rhythm? • To treat effectively means knowing the differential diagnoses • Use patient clues • ALWAYS obtain a proper 12-lead ECG • ECG “quick look” • Narrow or wide complex? • Regularity? • Possible preexcitation? • Ischemic changes?

  5. Narrow Complex Tachycardia • Differential diagnoses • Sinus tachycardia • Atrial tachycardia • AV nodal reentrant tachycardia • Orthodromic AV reciprocating tachycardia (CMT) • Atrial fibrillation/flutter • Unusual VTs • Look for P-waves • Let the PR-RP relationship help you

  6. Looking at the PR-RP intervals • Long RP tachycardia • Sinus tachycardia • Atrial tachycardia • Some AVRTs • Junctional tachycardia • Aytypical AVNRT • Short RP tachycardia • Typical AVNRT • Most AVRTs • Atach with long PR interval PR RP RP PR RP<PR (Short RP) RP>PR (Long RP)

  7. Acute therapies for SVT • Many SVTs depend on the AV node for perpetuation (e.g. AVNRT, AVRT, etc) • Try affecting AV nodal conduction to terminate the tachycardia • Valsalva • CSM • Adenosine • Beta-blockers, Ca channel antagonists

  8. “pseudo-R’”

  9. AV Nodal Reentrant Tachycardia (AVNRT) • Most common reentrant SVT • May achieve rates >200 bpm • Look for the psuedo-R’ in V1 or NO P wave AT ALL! • AV node dependent! • Most common type (>90%) is the slow-fast variety (typical)

  10. Initiation of AVNRT

  11. Atrial tachycardia • Can be an incessant rhythm • Rate: usually <220 bpm • Does not need the AV node for perpetuation • Adenosine response: • Transient AV block WITHOUT termination • Transient AV block WITH termination (40%) • Use your knowledge of the AV node to make the diagnosis

  12. Atrioventricular Reciprocating Tachycardia (AVRT) • Can be orthodromic (most common) or antidromic (very uncommon) • Needs AV node to perpetuate rhythm • Always associated with an AV bypass tract • May mimic AVNRT and atrial tachycardia • Can be short or long RP

  13. Therapies II • Some atrial tachycardias (about 40%) can be terminated with adenosine • Atrial flutter and fibrillation are not terminated by changing AV nodal conduction • Consider rate control • Electrical or chemical cardioverision • RF ablation

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