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Overview of the acute management of tachyarrhythmias

Jordan M Prutkin, MD, MHS, FHRS
Section Editors
James Hoekstra, MD
Hugh Calkins, MD
Deputy Editor
Brian C Downey, MD, FACC


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.


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'.)

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Literature review current through: Nov 2017. | This topic last updated: Sep 28, 2016.
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