Tachycardia

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Introduction

Differentiation between supraventricular tachycardias (SVT) and ventricular tachycardias (VT) can be challenging, especially in acute emergency settings. SVT's are rhythm disturbances in the atria or AV-nodal ring or rhythm disorders in which these structures are involved. VT's are rhythm disorders that only involve the ventricles. It can both take place in the myocardial tissue and the conduction system tissue.

Definitions:

Tachycardia:

heartrate > 100 bpm

Overview:

(Figure: Atrial ventricular)

Supra-ventricular tachycardia

AV node arrhythmias

Ventricular tachycardia

Differentiation between SVT and VT

To differentiate between supraventricular tachycardias and ventricular tachycardias a 12 lead ECG is the cornerstone of the diagnostic process. At first, the physician has to make a differentiation between a small or broad complex tachycardia.

Definitions:

Small complex tachycardia:

QRS duration < 120 ms.

A small complex tachycardia is most likely to be a SVT. However, also a septal VT or His-tachycardia can appear as a small complex tachycardia.

Broad complex tachycardia:

QRS duration > 120 ms.

A broad complex tachycardia can be due to a SVT with aberration, pre-exited tachycardia (eg antidrome re-entry tachycardia) or VT.

Differentiation:

(Figure 1, small complex tachy algorithm) (Figure 2, broad complex tachy algorithm)

Treatment:

Haemodynamical instability (high heartrate, low blood pressure):

• electrical cardioversion

Haemodynamical stability in a regular small complex tachycardia:

• Carotid massage (after palpation and ausculatation of carotid arteries for exclusion of carotid occlusion/stenosis)
• Vasalva manoevre
• Adenosine bolus (if patient is not asthmatic or having COPD)
• Verapamil (if patient is not having systolic heart failure)
• Beta-blocker (if patient is not having systolic heart failure)

Haemodynamical stability in a regular monomorphic broadcomplex tachycardia (systolic blood pressure >100 mmHg:

• Procaïnamide
• Amiodaron