Focal atrial tachycardia
- Peter Kistler, MBBS, FRACP, PhD
Peter Kistler, MBBS, FRACP, PhD
- Associate Professor of Medicine
- Head, Clinical Electrophysiology Research
- Baker IDI Heart & Diabetes Institute
Atrial tachycardia (AT) is a regular atrial rhythm at a constant rate of >100 beats per minute originating outside of the sinus node (waveform 1) . Focal ATs arise from a single site within the left or right atrium, in contrast to macroreentrant atrial arrhythmias (eg, atrial flutter) and atrial fibrillation, which involve multiple sites or larger circuits.
In the past, focal ATs were considered to be due predominantly to enhanced automaticity. Thus, they were often referred to as automatic ATs. However, the more inclusive term focal AT is preferred, as this encompasses automatic, triggered, and microreentrant etiologies that cannot be distinguished easily on the surface electrocardiogram.
Focal ATs are usually paroxysmal and self-limited, although in some patients, focal AT may be present nearly continuously (ie, incessant AT). Incessant AT is important as it may be associated with left ventricular dysfunction . (See "Arrhythmia-induced cardiomyopathy", section on 'Atrial tachycardia'.)
The characteristics and management of the common, repetitive forms of focal AT are discussed here. Macroreentrant atrial arrhythmias (eg, atrial flutter), atrial fibrillation, and other forms of supraventricular tachycardia are discussed in detail separately. (See "Overview of atrial flutter" and "Overview of atrial fibrillation" and "Clinical manifestations, diagnosis, and evaluation of narrow QRS complex tachycardias".)
Definition — In 2001, the Joint Expert Group from the Working Group of Arrhythmias of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology (now called the Heart Rhythm Society) classified regular ATs according to electrophysiologic mechanisms and anatomy . The Joint Expert Group defined focal AT as "being characterized by atrial activation starting rhythmically at a small area (focus) from where it spreads centrifugally." This definition indicates that the arrhythmia arises from an area that is smaller than would be required for classical macroreentry, which conventionally is considered to be a circuit greater than 2 cm in diameter.
- Saoudi N, Cosío F, Waldo A, et al. A classification of atrial flutter and regular atrial tachycardia according to electrophysiological mechanisms and anatomical bases; a Statement from a Joint Expert Group from The Working Group of Arrhythmias of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Eur Heart J 2001; 22:1162.
- Medi C, Kalman JM, Haqqani H, et al. Tachycardia-mediated cardiomyopathy secondary to focal atrial tachycardia: long-term outcome after catheter ablation. J Am Coll Cardiol 2009; 53:1791.
- Chen SA, Chiang CE, Yang CJ, et al. Sustained atrial tachycardia in adult patients. Electrophysiological characteristics, pharmacological response, possible mechanisms, and effects of radiofrequency ablation. Circulation 1994; 90:1262.
- Roberts-Thomson KC, Kistler PM, Kalman JM. Atrial tachycardia: mechanisms, diagnosis, and management. Curr Probl Cardiol 2005; 30:529.
- Roberts-Thomson KC, Kistler PM, Kalman JM. Focal atrial tachycardia I: clinical features, diagnosis, mechanisms, and anatomic location. Pacing Clin Electrophysiol 2006; 29:643.
- Page RL, Joglar JA, Caldwell MA, et al. 2015 ACC/AHA/HRS Guideline for the Management of Adult Patients With Supraventricular Tachycardia: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation 2016; 133:e506.
- Higa S, Tai CT, Lin YJ, et al. Focal atrial tachycardia: new insight from noncontact mapping and catheter ablation. Circulation 2004; 109:84.
- De Groot NM, Schalij MJ. Fragmented, long-duration, low-amplitude electrograms characterize the origin of focal atrial tachycardia. J Cardiovasc Electrophysiol 2006; 17:1086.
- Kistler PM, Sanders P, Hussin A, et al. Focal atrial tachycardia arising from the mitral annulus: electrocardiographic and electrophysiologic characterization. J Am Coll Cardiol 2003; 41:2212.
- Kistler PM, Roberts-Thomson KC, Haqqani HM, et al. P-wave morphology in focal atrial tachycardia: development of an algorithm to predict the anatomic site of origin. J Am Coll Cardiol 2006; 48:1010.
- Wong MC, Kalman JM, Ling LH, et al. Left septal atrial tachycardias: electrocardiographic and electrophysiologic characterization of a paraseptal focus. J Cardiovasc Electrophysiol 2013; 24:413.
- Ouyang F, Ma J, Ho SY, et al. Focal atrial tachycardia originating from the non-coronary aortic sinus: electrophysiological characteristics and catheter ablation. J Am Coll Cardiol 2006; 48:122.
- Akhtar, M. Supraventricular tachycardias. Electrophysiologic mechanisms, diagnosis and pharmacologic therapy. In: Tachycardias: Mechanisms, Diagnosis, Treatment, Josephson, ME, Wellens, H (Eds), Lea & Febiger, Philadelphia 1984. p.137.
- Levine HD, Smith C Jr. Repetitive paroxysmal tachycardia in adults. Cardiology 1970; 55:2.
- Sung RJ. Incessant supraventricular tachycardia. Pacing Clin Electrophysiol 1983; 6:1306.
- Gillette PC, Smith RT, Garson A Jr, et al. Chronic supraventricular tachycardia. A curable cause of congestive cardiomyopathy. JAMA 1985; 253:391.
- Gillette PC, Wampler DG, Garson A Jr, et al. Treatment of atrial automatic tachycardia by ablation procedures. J Am Coll Cardiol 1985; 6:405.
- Packer DL, Bardy GH, Worley SJ, et al. Tachycardia-induced cardiomyopathy: a reversible form of left ventricular dysfunction. Am J Cardiol 1986; 57:563.
- Bertil Olsson S, Blomström P, Sabel KG, William-Olsson G. Incessant ectopic atrial tachycardia: successful surgical treatment with regression of dilated cardiomyopathy picture. Am J Cardiol 1984; 53:1465.
- Doig JC, McComb JM, Reid DS. Incessant atrial tachycardia accelerated by pregnancy. Br Heart J 1992; 67:266.
- Chen SA, Tai CT, Chiang CE, et al. Focal atrial tachycardia: reanalysis of the clinical and electrophysiologic characteristics and prediction of successful radiofrequency ablation. J Cardiovasc Electrophysiol 1998; 9:355.
- Koike K, Hesslein PS, Finlay CD, et al. Atrial automatic tachycardia in children. Am J Cardiol 1988; 61:1127.
- Kistler PM, Sanders P, Fynn SP, et al. Electrophysiological and electrocardiographic characteristics of focal atrial tachycardia originating from the pulmonary veins: acute and long-term outcomes of radiofrequency ablation. Circulation 2003; 108:1968.
- O'Neill MD, Wright M, Knecht S, et al. Long-term follow-up of persistent atrial fibrillation ablation using termination as a procedural endpoint. Eur Heart J 2009; 30:1105.
- Verma A, Jiang CY, Betts TR, et al. Approaches to catheter ablation for persistent atrial fibrillation. N Engl J Med 2015; 372:1812.
- Zipes DP, Gaum WE, Genetos BC, et al. Atrial tachycardia without P waves masquerading as an A-V junctional tachycardia. Circulation 1977; 55:253.
- Qian ZY, Hou XF, Xu DJ, et al. An algorithm to predict the site of origin of focal atrial tachycardia. Pacing Clin Electrophysiol 2011; 34:414.
- Kang KT, Etheridge SP, Kantoch MJ, et al. Current management of focal atrial tachycardia in children: a multicenter experience. Circ Arrhythm Electrophysiol 2014; 7:664.
- Lesh MD, Van Hare GF, Epstein LM, et al. Radiofrequency catheter ablation of atrial arrhythmias. Results and mechanisms. Circulation 1994; 89:1074.
- Marchlinski F, Callans D, Gottlieb C, et al. Magnetic electroanatomical mapping for ablation of focal atrial tachycardias. Pacing Clin Electrophysiol 1998; 21:1621.
- Natale A, Breeding L, Tomassoni G, et al. Ablation of right and left ectopic atrial tachycardias using a three-dimensional nonfluoroscopic mapping system. Am J Cardiol 1998; 82:989.
- Kay GN, Chong F, Epstein AE, et al. Radiofrequency ablation for treatment of primary atrial tachycardias. J Am Coll Cardiol 1993; 21:901.
- Poty H, Saoudi N, Haissaguerre M, et al. Radiofrequency catheter ablation of atrial tachycardias. Am Heart J 1996; 131:481.
- Scheinman MM, Huang S. The 1998 NASPE prospective catheter ablation registry. Pacing Clin Electrophysiol 2000; 23:1020.
- Lesh MD. Radiofrequency catheter ablation of atrial tachycardia and flutter. In: Cardiac Electrophysiology: From Cell to Bedside, 2nd ed, Zipes DP, Jalife J (Eds), WB Saunders, Philadelphia 1995. p.1461.
- Gillette PC, Garson A Jr. Electrophysiologic and pharmacologic characteristics of automatic ectopic atrial tachycardia. Circulation 1977; 56:571.
- Iwai S, Markowitz SM, Stein KM, et al. Response to adenosine differentiates focal from macroreentrant atrial tachycardia: validation using three-dimensional electroanatomic mapping. Circulation 2002; 106:2793.
- Keane JF, Plauth WH, Nadas AS. Chronic ectopic tachycardia of infancy and childhood. Am Heart J 1972; 84:748.
- Yoshimura H, Ishikawa T, Kuji N, et al. Two cases of dilated cardiomyopathy associated with incessant supraventricular tachycardia who showed a favorable response to beta-blockade. Heart Vessels Suppl 1990; 5:88.
- Berns E, Rinkenberger RL, Jeang MK, et al. Efficacy and safety of flecainide acetate for atrial tachycardia or fibrillation. Am J Cardiol 1987; 59:1337.
- Brugada P, Abdollah H, Wellens HJ. Suppression of incessant supraventricular tachycardia by intravenous and oral encainide. J Am Coll Cardiol 1984; 4:1255.
- Anguera I, Brugada J, Roba M, et al. Outcomes after radiofrequency catheter ablation of atrial tachycardia. Am J Cardiol 2001; 87:886.
- MECHANISMS AND ETIOLOGY
- Electrophysiologic mechanisms
- Sites of origin
- Associated conditions
- - Incessant AT resulting in cardiomyopathy
- - Post-atrial fibrillation ablation
- - Digitalis toxicity
- CLINICAL FEATURES
- Electrocardiographic features
- - P waves
- - Atrioventricular relationship
- - QRS morphology
- Localization of AT focus
- Electrophysiologic study and catheter ablation
- Acute treatment
- Chronic or maintenance therapy
- - Catheter ablation
- - Anticoagulation
- Treatment of incessant AT
- SUMMARY AND RECOMMENDATIONS