A synopsis of - Management of Common Arrhythmias: Part I. Supraventricular Arrhythmias
A. KESH HEBBAR, M.D., and WILLIAM J. HUESTON, M.D. Medical University of South Carolina, Charleston, South Carolina
Am Fam Physician. 2002 Jun 15;65(12):2479-2487.
http://www.aafp.org/afp/2002/0615/p2479.pdf
Most arrhythmias are usually benign, but those that are not, require treatment. The most common arrhythmia is atrial fibrillation. Most risk factors are associated with ischemic or structural heart disease, including hypertension, left ventricular hypertrophy, cardiomyopathies, COPD, and CAD. If the left atrium is not enlarged and the onset of the fibrillation is within the last year, then the patient has a better chance of maintaining sinus rhythm after treatment. Rhythm control through cardioversion can be done If the patient has been in atrial fibrillation for less than 48 hours and does not have any atrial thrombi on echocardiogram. Anticoagulation should be started before cardioversion. If thrombi are found on echocardiogram, anticoagulation may be needed for at least 3 weeks before cardioversion is considered. Synchronized electrical cardioversion is the treatment of choice. Medications such as amiodarone, and to a lesser extent quinidine, procainamide and disopyramide can be used for cardioversion as well. Radiofrequency ablation or a pacemaker are other options to consider. Rate control can be used in patients who do not qualify for rhythm control, or those with atrial fibrillation with rapid ventricular response. Calcium channel blockers (diltiazem and verapamil), beta blockers (propranolol and esmolol), or digoxin can be considered for rate control.
Paroxysmal supraventricular tachycardia is the most common type of SVT, and will be the focus of this part of the article. AV nodal reentry SVT occurs when there are two pathways that conduct the impulse at different rates. It is a narrow complex tachycardia without p waves. The rate is usually 160-190 BPMs. If there is a concomitant branch block, the tachycardia may have a wide complex. Wolff-Parkinson-White syndrome is a PSVT with an accessory pathway. There will be a shortened PR interval and the classic "delta wave on the QRS complex. If the cause of the SVT is due to increased automaticity, the atrium will be enlarged. The stretch atria will cause multiple premature beats and irregular p wave morphologies (also known as multifocal atrial tachycardia if three or more can be found). In most cases of PSVT, it is benign and self limited. If there is hemostatic instability, electrical cardioversion should be strongly considered. Symptomatic treatment can be done with vagal maneuvers, adenosine, calcium channel blockers, or beta blockers. Long term control for WPW or nodal reentry SVT may require radiofrequency ablation.
Sinus arrhythmia is normal in athletes and young adults. It is asymptomatic and can be resolved by holding ones breath. Occasionally it may be seen in patients with digoxin overdose and ICP. A wandering atrial pacemaker will present on an ECG as variable p waves and PR intervals. These are incidental findings and do not require treatment. Premature atrial complexes will have P waves of a different morphology because the impulse is from a different atrial focus. They do not require treatment, but a beta blocker may help if the patient is having symptoms.
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