Overview of the acute management of tachyarrhythmias
- Jordan M Prutkin, MD, MHS, FHRS
Jordan M Prutkin, MD, MHS, FHRS
- Associate Professor of Medicine, Division of Cardiology, Electrophysiology Section
- University of Washington
- Section Editors
- James Hoekstra, MD
James Hoekstra, MD
- Section Editor — Adult Cardiology Emergencies
- Professor and Fredrick Glass Chair
- Wake Forest University
- Hugh Calkins, MD
Hugh Calkins, MD
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Johns Hopkins Medical Institutions
Tachyarrhythmias, defined as abnormal heart rhythms with a ventricular rate of 100 or more beats per minute, are frequently symptomatic and often result in patients seeking care at their provider's office or the emergency department. Signs and symptoms related to the tachyarrhythmia may include shock, hypotension, heart failure, shortness of breath, chest pain, acute myocardial infarction, palpitations, and/or decreased level of consciousness. An overview of the management of these various arrhythmias will be presented here. More complete reviews of the individual arrhythmias are discussed separately.
INITIAL DIAGNOSTIC AND TREATMENT DECISIONS
In anyone who presents with a symptomatic tachyarrhythmia, a 12-lead electrocardiogram (ECG) should be obtained while a brief initial assessment of the patient's overall clinical assessment is performed. If the patient is hemodynamically unstable, it may be preferable to obtain only a rhythm strip prior to urgent cardioversion and not wait for a 12-lead ECG. The information acquired from these initial assessments is crucial for subsequent management of the patient.
Is the patient clinically (or hemodynamically) unstable? — The most important clinical determination in a patient presenting with a tachyarrhythmia is whether or not the patient is experiencing signs and symptoms related to the rapid heart rate. These can include hypotension, shortness of breath, chest pain suggestive of coronary ischemia, shock, and/or decreased level of consciousness.
Determining whether a patient's symptoms are related to the tachycardia depends upon several factors, including age and the presence of underlying cardiac disease.
●Hemodynamically unstable and not sinus rhythm – If a patient has clinically significant hemodynamic instability potentially due to the tachyarrhythmia, an attempt should be made as quickly as possible to determine whether the rhythm is sinus tachycardia (algorithm 1). If the rhythm is not sinus tachycardia, or if there is any doubt that the rhythm is sinus tachycardia, urgent conversion to sinus rhythm is recommended. (See "Clinical manifestations, diagnosis, and evaluation of narrow QRS complex tachycardias", section on 'Similar to sinus rhythm' and "Basic principles and technique of electrical cardioversion and defibrillation" and "Approach to the diagnosis of wide QRS complex tachycardias", section on 'Assessment of stability'.)
- Link MS. Clinical practice. Evaluation and initial treatment of supraventricular tachycardia. N Engl J Med 2012; 367:1438.
- 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. J Am Coll Cardiol 2016; 67:e27.
- Kalbfleisch SJ, el-Atassi R, Calkins H, et al. Differentiation of paroxysmal narrow QRS complex tachycardias using the 12-lead electrocardiogram. J Am Coll Cardiol 1993; 21:85.
- INITIAL DIAGNOSTIC AND TREATMENT DECISIONS
- Is the patient clinically (or hemodynamically) unstable?
- Is the QRS complex narrow or wide? Regular or irregular?
- NARROW QRS COMPLEX TACHYARRHYTHMIAS
- Regular narrow QRS complex tachyarrhythmias
- - Sinus tachycardia
- - Atrioventricular nodal reentrant tachycardia (AVNRT)
- - Atrioventricular reentrant tachycardia (AVRT)
- - Atrial tachycardia
- - Atrial flutter
- Irregular narrow QRS complex tachyarrhythmias
- - Atrial fibrillation
- - Atrial flutter
- - Multifocal atrial tachycardia
- WIDE QRS COMPLEX TACHYARRHYTHMIAS
- Regular wide QRS complex tachyarrhythmias
- - Ventricular tachycardia
- - Supraventricular tachycardia with aberrant conduction
- - Supraventricular tachycardia with a pacemaker
- - Antidromic AVRT
- Irregular wide QRS complex tachyarrhythmias
- - Polymorphic ventricular tachycardia
- - Preexcited atrial fibrillation
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS