Multifocal atrial tachycardia
- Alfred Buxton, MD
Alfred Buxton, MD
- Professor of Medicine, Harvard Medical School
- Director, Clinical Electrophysiology Laboratory
- Beth Israel Deaconess Medical Center
Multifocal atrial tachycardia (MAT) is an arrhythmia that can be seen in a variety of clinical disorders . In addition to a heart rate greater than 100 beats per minute, the characteristic electrocardiographic feature is variability in P wave morphology, with each unique P wave morphology felt to indicate a different site of atrial origin. Although this abnormality had been noted for many years during some types of atrial tachycardia, the term MAT became commonplace terminology in the late 1960s . Patients with multiple P wave morphologies but a normal heart rate (60 to 100 beats per minute) are considered to have a wandering atrial pacemaker, since the heart rate does not meet criteria for a tachycardia. (See 'Terminology' below.)
This topic will review the definition, pathogenesis, etiology, and treatment of MAT in adults. Other tachycardias of atrial origin, as well as the discussion of this arrhythmia in children, are reviewed separately. (See "Focal atrial tachycardia" and "Atrial tachycardias in children" and "Atrioventricular nodal reentrant tachycardia" and "Atrioventricular reentrant tachycardia (AVRT) associated with an accessory pathway" and "Overview of atrial fibrillation".)
DEFINITION, PATHOGENESIS, AND PREVALENCE
As with any tachycardia, the heart rate in MAT exceeds 100 beats per minute. To distinguish MAT from other tachyarrhythmias of atrial origin, there should be organized atrial activity yielding P waves with three or more different morphologies. (See 'Clinical manifestations and diagnosis' below.)
Terminology — A number of authors have used the term "chaotic" to describe MAT [3-5]. However, chaos in modern usage in nonlinear dynamics and mathematics implies there is order in what appear to be random events . A more accurate term for this arrhythmia is probably "multiform" as there is no proof that the arrhythmia is actually multifocal, although multifocal remains the commonly used term .
The tachycardic threshold for multifocal atrial tachycardia (MAT) has traditionally been set at 100 bpm, but a review of 60 patients with multifocal atrial arrhythmias found a stronger association between the incidence of COPD exacerbations and the diagnosis of MAT if a threshold of 90 bpm was used .
- Kastor JA. Multifocal atrial tachycardia. N Engl J Med 1990; 322:1713.
- Shine KI, Kastor JA, Yurchak PM. Multifocal atrial tachycardia. Clinical and electrocardiographic features in 32 patients. N Engl J Med 1968; 279:344.
- Berlinerblau R, Feder W. Chaotic atrial rhythm. J Electrocardiol 1972; 5:135.
- Bisset GS 3rd, Seigel SF, Gaum WE, Kaplan S. Chaotic atrial tachycardia in childhood. Am Heart J 1981; 101:268.
- Gavrilescu S, Luca C. Chaotic atrial rhythm: Studies with His bundle electrography. Eur J Cardiol 1974; 2:153.
- Glass L, Mackey MC. From Clocks to Chaos: The Rhythms of Life, Princeton University Press, Princeton, NJ 1988.
- Kothari SA, Apiyasawat S, Asad N, Spodick DH. Evidence supporting a new rate threshold for multifocal atrial tachycardia. Clin Cardiol 2005; 28:561.
- Yokoshiki H, Mitsuyama H, Watanabe M, Tsutsui H. Swallowing-induced multifocal atrial tachycardia originating from right pulmonary veins. J Electrocardiol 2011; 44:395.e1.
- Marchlinski FE, Miller JM. Atrial arrhythmias exacerbated by theophylline. Response to verapamil and evidence for triggered activity in man. Chest 1985; 88:931.
- Levine JH, Michael JR, Guarnieri T. Treatment of multifocal atrial tachycardia with verapamil. N Engl J Med 1985; 312:21.
- Santos-Ocampo CD, Sadaniantz A, Elion JL, et al. Echocardiographic assessment of the cardiac anatomy in patients with multifocal atrial tachycardia: a comparison with atrial fibrillation. Am J Med Sci 1994; 307:264.
- Engel TR, Radhagopalan S. Treatment of multifocal atrial tachycardia by treatment of pulmonary insufficiency: or is it vice versa? Chest 2000; 117:7.
- Wang K, Goldfarb BL, Gobel FL, Richman HG. Multifocal atrial tachycardia. Arch Intern Med 1977; 137:161.
- Lipson MJ, Naimi S. Multifocal atrial tachycardia (chaotic atrial tachycardia). Clinical associations and significance. Circulation 1970; 42:397.
- Goudis CA, Konstantinidis AK, Ntalas IV, Korantzopoulos P. Electrocardiographic abnormalities and cardiac arrhythmias in chronic obstructive pulmonary disease. Int J Cardiol 2015; 199:264.
- Hudson LD, Kurt TL, Petty TL, Genton E. Arrhythmias associated with acute respiratory failure in patients with chronic airway obstruction. Chest 1973; 63:661.
- Levine JH, Michael JR, Guarnieri T. Multifocal atrial tachycardia: a toxic effect of theophylline. Lancet 1985; 1:12.
- Hazard PB, Burnett CR. Verapamil in multifocal atrial tachycardia. Hemodynamic and respiratory changes. Chest 1987; 91:68.
- Tutar E, Kaya A, Güleç S, et al. Echocardiographic evaluation of left ventricular diastolic function in chronic cor pulmonale. Am J Cardiol 1999; 83:1414.
- Moustapha A, Kaushik V, Diaz S, et al. Echocardiographic evaluation of left-ventricular diastolic function in patients with chronic pulmonary hypertension. Cardiology 2001; 95:96.
- Iseri LT, Fairshter RD, Hardemann JL, Brodsky MA. Magnesium and potassium therapy in multifocal atrial tachycardia. Am Heart J 1985; 110:789.
- Phillips J, Spano J, Burch G. Chaotic atrial mechanism. Am Heart J 1969; 78:171.
- Chung EK. Appraisal of multifocal atrial tachycardia. Br Heart J 1971; 33:500.
- 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.
- McCord JK, Borzak S, Davis T, Gheorghiade M. Usefulness of intravenous magnesium for multifocal atrial tachycardia in patients with chronic obstructive pulmonary disease. Am J Cardiol 1998; 81:91.
- Strickberger SA, Miller CB, Levine JH. Multifocal atrial tachycardia from electrolyte imbalance. Am Heart J 1988; 115:680.
- Parrillo JE. Treating multifocal atrial tachycardia (MAT) in a critical care unit: New data regarding verapamil and metoprolol. Update Crit Care Med 1987; 2:1, 3-5.
- Schettini B, Katz S, Zeldis SM. Verapamil in tachycardia therapy. Chest 1986; 89:616.
- Mukerji V, Alpert MA, Diaz-Arias M, Sanfelippo JF. Termination and suppression of multifocal atrial tachycardia with verapamil. South Med J 1987; 80:269.
- Salerno DM, Anderson B, Sharkey PJ, Iber C. Intravenous verapamil for treatment of multifocal atrial tachycardia with and without calcium pretreatment. Ann Intern Med 1987; 107:623.
- Hanau SP, Solar M, Arsura EL. Metoprolol in the treatment of multifocal atrial tachycardia. Cardiovasc Rev Rep 1984; 5:1182.
- Arsura EL, Solar M, Lefkin AS, et al. Metoprolol in the treatment of multifocal atrial tachycardia. Crit Care Med 1987; 15:591.
- Hazard PB, Burnett CR. Treatment of multifocal atrial tachycardia with metoprolol. Crit Care Med 1987; 15:20.
- Byrd RC, Sung RJ, Marks J, Parmley WW. Safety and efficacy of esmolol (ASL-8052: an ultrashort-acting beta-adrenergic blocking agent) for control of ventricular rate in supraventricular tachycardias. J Am Coll Cardiol 1984; 3:394.
- Aronow WS, Van Camp S, Turbow M, et al. Acebutolol in supraventricular arrhythmias. Clin Pharmacol Ther 1979; 25:149.
- Williams DO, Tatelbaum R, Most AS. Effective treatment of supraventricular arrhythmias with acebutolol. Am J Cardiol 1979; 44:521.
- Pierce WJ, McGroary K. Multifocal atrial tachycardia and Ibutilide. Am J Geriatr Cardiol 2001; 10:193.
- Kones RJ, Phillips JH, Hersh J. Mechanism and management of chaotic atrial mechanism. Cardiology 1974; 59:92.
- Ueng KC, Lee SH, Wu DJ, et al. Radiofrequency catheter modification of atrioventricular junction in patients with COPD and medically refractory multifocal atrial tachycardia. Chest 2000; 117:52.
- DEFINITION, PATHOGENESIS, AND PREVALENCE
- Associated arrhythmias
- ASSOCIATED CLINICAL CONDITIONS
- Pulmonary disease
- Cardiac disease
- Interactions between cardiac and pulmonary disease
- MAT in children and young adults
- CLINICAL MANIFESTATIONS AND DIAGNOSIS
- Differential diagnosis
- Magnesium and potassium repletion
- Pharmacologic therapy
- - Non-dihydropyridine calcium channel blockers
- - Beta blockers
- - Precautions with verapamil and beta blockers
- - Which to use first: Calcium channel blocker or beta blocker?
- Antiarrhythmic drugs
- DC cardioversion
- Radiofrequency ablation
- SUMMARY AND RECOMMENDATIONS