Sinus tachycardia: Evaluation and management
- Munther K Homoud, MD
Munther K Homoud, MD
- Associate Professor of Medicine
- Tufts University School of Medicine
Sinus tachycardia is a rhythm in which the rate of impulses arising from the sinoatrial (SA) node is elevated. It is one of the most commonly encountered, and often overlooked, rhythm disturbances that may portend an adverse prognosis, particularly in patients with cardiovascular disease [1-3].
The normal adult heart rate, arising from the sinoatrial (SA) node, has been considered historically to range from 60 to 100 beats per minute, with sinus tachycardia being defined as a sinus rhythm with a rate exceeding 100 beats per minute. However, the "normal" heart rate is, in part, the result of the complex interplay between the sympathetic and parasympathetic nervous systems. It is affected by numerous factors and varies in part with age (table 1). The heart rate is usually between 110 and 150 beats per minute in infants, with gradual slowing over the next six years. The resting sinus rate in older children and adults is approximately 65 to 85 beats per minute, with some authors suggesting a slowing in older age [4-6]. There is also considerable variation based upon level of fitness and underlying medical comorbidities. (See "Normal sinus rhythm and sinus arrhythmia".)
The etiology, clinical presentation, evaluation, and management of sinus tachycardia, including inappropriate sinus tachycardia, will be reviewed here. Other supraventricular tachycardias, including sinoatrial reentry supraventricular tachycardia (which involves tissue from the SA node), are discussed elsewhere. (See "Overview of the acute management of tachyarrhythmias", section on 'Narrow QRS complex tachyarrhythmias' and "Clinical manifestations, diagnosis, and evaluation of narrow QRS complex tachycardias" and "Sinoatrial nodal reentrant tachycardia (SANRT)".)
DEFINITION AND ECG FEATURES
Normal sinus rhythm (NSR) is the characteristic rhythm of the healthy human heart. NSR is considered to be present in adults if the heart rate is between 60 and 100 beats per minute, the P waves on the electrocardiogram (ECG) are normal (unless there is concurrent atrial disease), and the rate does not vary significantly (waveform 1). The normal sinus P wave demonstrates right followed by left atrial depolarization and is a low amplitude positive deflection preceding the QRS complex. The duration is generally <120 milliseconds (three small boxes) and the amplitude <0.25 millivolts (2.5 small boxes). (See "ECG tutorial: Basic principles of ECG analysis", section on 'P wave'.)
By conventional definition, a tachycardia requires the heart rate to be greater than 100 beats per minute. As such, sinus tachycardia can be thought of as sinus rhythm (normal-appearing P waves on surface ECG) which is occurring at a rate of greater than 100 beats per minute (waveform 2).
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- DEFINITION AND ECG FEATURES
- CLINICAL PRESENTATION
- Sinus tachycardia as a physiologic response
- Postural orthostatic tachycardia syndrome
- Inappropriate sinus tachycardia
- DIAGNOSTIC EVALUATION
- Differential diagnosis
- Confirm sinus tachycardia
- Further evaluation
- Acute myocardial infarction
- Inappropriate sinus tachycardia
- - Beta blockers
- - Ivabradine
- - Catheter ablation
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS