Highlights & Basics
- Occurs in the settings of coronary artery disease, congestive heart failure, cardiac surgery, catecholamine ingestion, digoxin toxicity, and alcohol dependency.
- Symptoms and signs include palpitations, fatigue, presyncope/syncope, chest pain.
- ECG shows a regular atrial tachycardia with P-wave morphology different from that in sinus tachycardia.
- Treatment consists of a trial of adenosine, withdrawal of the causative agent, or treatment of the underlying cause. For sustained tachycardias, cardiology consultation, class Ia/Ic or III antiarrhythmic agents, and ablative therapy are appropriate.
- Complications include hemodynamic instability and congestive heart failure.
Quick Reference
History & Exam
Key Factors
cardiac disease
Other Factors
medications
palpitations
fatigue, weakness
chest pain
shortness of breath, cough
nausea, vomiting
lightheadedness, syncope
rales
edema
Diagnostics Tests
1st Tests to Order
ECG
digoxin level
theophylline level
CXR
electrolytes
toxicology screen
Other Tests to consider
vagal maneuvers, adenosine
thyroid-stimulating hormone
echocardiogram
ambulatory 24-hour (Holter) ECG or event recorder
electrophysiologic study (EPS)
Treatment Options
presumptive
adult: undifferentiated supraventricular tachycardia
adenosine
acute
adult: focal AT; digoxin excess not suspected
hemodynamically stable focal AT
hemodynamically unstable focal AT
Definition
Classifications
Atrial tachycardias
- Sinus tachycardia: regular tachycardia with uniform P wave before every QRS. Rate shows gradual variation in response to sympathetic/parasympathetic stimulation.
- Focal atrial tachycardia: recurrent, regular tachycardia with a fixed heart rate at 100 to 250 bpm. P waves are visible before every QRS, and are uniform in their appearance when looking at a single lead. Onset and termination of arrhythmia are abrupt.
- AV node re-entry tachycardia: regular tachycardia with a fixed rate in the range of 140 to 280 bpm. P waves may be visible, but usually follow the QRS complex with a short R-P interval.
- Multifocal atrial tachycardia: irregular tachycardia at a rate of 120 to 200 bpm. P waves occur before every QRS, and there are at least three different P-wave morphologies when looking at a single lead.
- Atrial flutter: new-onset atrial flutter usually has a fixed heart rate of 145 to 150 bpm due to 2:1 AV block and an atrial flutter rate of 300 bpm. When medicated with AV node-blocking agents, the heart rate may be irregular, indicating variable AV block.
- Atrial fibrillation: irregular tachycardia with beat to beat variation in heart rate, P waves replaced by fibrillatory waves.
Vignette
Common Vignette 1
Common Vignette 2
Other Presentations
Epidemiology
Etiology
Pathophysiology
Images
Focal atrial tachycardia in an 88-year-old woman with 2:1 AV nodal block in the setting of digoxin therapy and potassium 2.8 mEq/L
Focal atrial tachycardia in a 35-year-old with history of recent cocaine use
ECG following cardioversion of focal atrial tachycardia in a 35-year-old with history of recent cocaine use
Focal atrial tachycardia in a 55-year-old with ischemic cardiomyopathy
Diagnostic algorithm for differentiating atrial tachycardias from other narrow QRS tachycardias. AV = atrioventricular, PAC = premature atrial contraction
Response to adenosine 6 mg intravenously
Diagnostic Approach
History/physical
ECG/Telemetry
Vagal maneuvers or adenosine
Further tests
Risk Factors
History & Exam
Tests
Differential Diagnosis
Differentiating Signs/Symptoms
- This arrhythmia is usually compensatory for a reduced stroke volume because of heart failure or volume depletion, or because of sympathetic stimulation from pain, fear, or exogenous catecholamines.
- The presence of a clinical disease state plus variation in the atrial rate will usually differentiate this arrhythmia from atrial tachycardia.
Differentiating Tests
- Vagal maneuvers/adenosine will cause sinus tachycardia to transiently slow down, with slowing of the sinus rate and prolongation of the PR interval before AV block (if it occurs).
Differentiating Signs/Symptoms
- This supraventricular tachycardia shares many of the causes of focal atrial tachycardia (focal AT). Hence, the two may be indistinguishable based on history and physical exam.
- On vagal maneuvers or administering adenosine, in contrast with focal AT, AV node re-entrant tachycardia will abruptly cease. After a pause, sinus rhythm will resume.
Differentiating Tests
- The 12-lead ECG may show P waves, which can be differentiated from the P waves of atrial tachycardia by the shortened RP interval created by retrograde activation of the atria.
- The P waves in atrial tachycardia are found in the second half of the tachycardia cycle (long RP/short PR intervals).
Atrial flutter
Differentiating Signs/Symptoms
- This supraventricular tachycardia shares many of the causes of focal AT. Hence, the two may be indistinguishable based on history and physical exam.
- Vagal maneuvers/adenosine will transiently slow the ventricular response rate with AV block. The characteristic flutter waves will be revealed and will be unaffected.
Differentiating Tests
- The 12-lead ECG will show a regular tachycardia with the ventricular response rate being a multiple of the atrial flutter rate (usually 300 bpm).
- Unmedicated flutter will usually present in 2:1 AV block with the ventricular response being 148 to 150 bpm.
- The flutter waves will typically distort the baseline, particularly in leads II, III, and AVF.
- When AV block is induced in atrial tachycardia, there is an isoelectric interval between P waves, which is not seen in atrial flutter.
Criteria
Treatment Approach
Differentiating the type of arrhythmia
General principles for treating patients with focal AT
Approach to initial treatment
Digoxin toxicity
Children
Treatment Options
adult: undifferentiated supraventricular tachycardia
adenosine
Primary Options
- adenosine
adults: 6 mg/dose intravenously initially, followed by 12 mg/dose in 1-2 minutes if no effect, may repeat 12 mg/dose once more in 1-2 minutes if no effect, maximum 30 mg/total dose
- adenosine
Comments
- Transient slowing of the ventricular response rate with sustained atrial activity indicates flutter or focal AT. Flutter will have the characteristic saw tooth pattern of an atrial macro-re-entrant circuit. Focal AT will show discrete P waves with an isoelectric baseline.
- Lack of response to adenosine suggests either sinus tachycardia or focal AT, and strongly suggests that the rhythm is not re-entrant supraventricular tachycardia or atrial flutter.
- Some forms of atrial tachycardia will break in response to adenosine.[15]
adult: focal AT; digoxin excess not suspected
hemodynamically stable focal AT
beta-blocker or calcium-channel blocker
Primary Options
- diltiazem
adults: 0.25 mg/kg intravenously initially, followed by 10 mg/hour infusion, consult specialist for further guidance on dose
- diltiazem
- esmolol
adults: 500 micrograms/kg/dose intravenously initially, followed by 50 micrograms/kg/minute infusion for 4 minutes, if no response after 5 minutes repeat loading dose and increase infusion, consult specialist for further guidance on dose
- esmolol
Secondary Options
- verapamil
adults: 5-10 mg intravenously initially, followed by 10 mg 30 minutes later if no effect, consult specialist for further guidance on dose
- verapamil
- metoprolol tartrate
adults: 5 mg/dose intravenously initially, may repeat every 5 minutes, maximum 3 doses
- metoprolol tartrate
Comments
- Calcium-channel blockers or beta-blockers may be helpful in controlling the ventricular response rate or breaking the tachycardia.[1]
- Catecholamine excess should be suspected if there is a history or suspicion of recent use of exogenous catecholamines, cocaine, or alcohol with clinical features of catecholamine excess (agitation, diaphoresis, hypertension).
- Supportive care and withdrawal of any offending agent are first-line therapy. Supportive care includes intravenous fluids for any hemodynamic instability without overt congestive heart failure, as well as correction of any associated electrolyte imbalance.
- Blocking the beta receptors leaves the circulating norepinephrine free to activate the alpha receptors with no opposing beta effects. This may induce hypertensive crisis and vasospasm.
- Beta-blockers are generally reserved for patients who are not suspected to have taken cocaine, and who are refractory to supportive care, show evidence of cardiac ischemia, or are hemodynamically unstable.
- The effects of any pharmacologic intervention for focal AT are often unpredictable given the multitude of causes and underlying mechanisms. For this reason, if there are any concerns about the potential risks of giving an agent to a stable patient, agents should be chosen that are short acting and can be stopped if there are adverse effects.
- Beta-blockers and calcium-channel blockers should be avoided in patients with decompensated heart failure or hemodynamic instability. Beta-blockers should also be avoided in patients with active pulmonary disease.
ibutilide or amiodarone
Primary Options
- ibutilide
adults (weight ≥60 kg): 1 mg intravenously over 10 minutes; adults (weight <60 kg): 0.01 mg/kg intravenously over 10 minutes; can repeat dose if arrhythmia does not terminate within 10 minutes after end of initial infusion
- ibutilide
- amiodarone
adults: 150 mg intravenously over 10 minutes, followed by 1 mg/minute infusion over 6 hours (total dose 360 mg), then 0.5 mg/minute infusion over 18 hours (total dose 540 mg)
- amiodarone
Comments
- Patients who are refractory or have contraindications to adenosine, beta-blockers, or calcium-channel blockers may benefit from these second-line medications.
- Amiodarone is a highly effective agent in the management of a wide range of supraventricular and ventricular tachycardias. It prolongs the duration of the action potential and the refractory period in atrial and ventricular tissues, slows automaticity in pacemaker cells, and slows AV nodal conduction. Patients should, therefore, be closely monitored when this treatment is started.
third-line pharmacotherapy or direct current (DC) cardioversion + cardiology consult
Primary Options
- flecainide
adults: 50 mg orally every 12 hours initially, increase gradually according to response, maximum 300 mg/day
- flecainide
- propafenone
adults: 150 mg orally (immediate-release) every 8 hours initially, increase gradually according to response, maximum 900 mg/day; 225 mg orally (extended-release) every 12 hours initially, increase gradually according to response, maximum 850 mg/day
- propafenone
Comments
- Patients who are refractory to second-line pharmacotherapy should be referred for a cardiology consult. Cardioversion may be effective in some cases; usually if re-entry is the mechanism. Other forms of focal AT are often resistant to electrical disruption. Medications that may be effective are in the Ic class of antiarrhythmics. Because of the risk of untoward side effects with these medications, cardiology consultation is advised when considering these therapies.
hemodynamically unstable focal AT
direct current (DC) cardioversion
Comments
- Electrical disruption may be effective in some cases of focal AT. When a patient has become unstable, it is reasonable to attempt DC cardioversion when it is clear that the tachyarrhythmia is nonsinus and is responsible for the hemodynamic compromise.
- Electrical disruption is usually only effective if re-entry is the mechanism; other forms of focal AT are typically resistant to electrical disruption.
- If an underlying cause is identified, this should be treated.
adult: focal AT; digoxin toxicity suspected
supportive care
Comments
- Digoxin toxicity should be suspected if there is a history of congestive heart failure, the patient is taking digoxin, and the rhythm is atrial tachycardia with evidence of atrioventricular blockade.
- When atrial tachycardia is a manifestation of digoxin toxicity, treatment is aimed at supportive care, withholding digoxin, optimizing volume status, and replacing potassium if there is a deficit.Image
- This approach is usually sufficient for restoring sinus rhythm.
Fab fragments
Primary Options
digoxin immune Fab
adults: consult specialist for guidance on dose
Comments
- Patients with evidence of refractory arrhythmias, particularly ventricular, or hemodynamically compromising AV block may benefit from digoxin-specific antibody fragments (Fab) therapy to bind digoxin.[18]
child
anti-arrhythmic medication ± catheter ablation
Comments
- Pediatric atrial tachycardias are uncommon. Atrial tachycardia in children is often incessant and refractory to typical treatments used for atrioventricular nodal re-entrant tachycardia; tachycardia-induced cardiomyopathy is commonly observed.
- The treatment of pediatric patients with atrial tachycardia includes medications to suppress the arrhythmia and/or control the ventricular response and catheter ablation. Beta-blockers, digoxin, and amiodarone are often effective as first-line pharmacologic interventions to achieve rate control. Many children will have spontaneous resolution of the arrhythmia.
- Amiodarone should not be used in babies <1 month old because of the additive benzyl alcohol, which may precipitate metabolic acidosis and gasping syndrome.[19]
- Patients with incessant tachycardias will usually require catheter ablation, which is associated with a high degree of success, a low complication rate, and a low recurrence rate.
- Selection of drug therapy in children should be under specialist guidance.
adult: sustained or recurrent focal AT
catheter ablation
Comments
- Many patients with sustained and/or recurrent atrial tachycardias are referred for catheter ablative therapy. The success of this treatment depends on the site of origin and underlying mechanism.[17]
- Catheter ablation is a specialized intervention undertaken by electrophysiologists.
Follow-Up Overview
Prognosis
Monitoring
Complications
Citations
1. 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 Apr 5;67(13):e27-e115.[Abstract][Full Text]
2. Salerno JC, Kertesz NJ, Friedman RA, et al. Clinical course of atrial ectopic tachycardia is age-dependent: results and treatment in children <3 or >3 or = 3 years of age. J Am Coll Cardiol. 2004 Feb 4;43(3):438-44.[Abstract]
3. Doniger SJ, Sharieff GQ. Pediatric dysrhythmias. Pediatr Clin North Am. 2006 Feb;53(1):85-105, vi.[Abstract]
4. Ferguson JD, DiMarco JP. Contemporary management of paroxysmal supraventricular tachycardia. Circulation. 2003 Mar 4;107(8):1096-9.[Abstract]
5. Poutiainen AM, Koistinen MJ, Airaksinen KE, et al. Prevalence and natural course of ectopic atrial tachycardia. Eur Heart J. 1999 May;20(9):694-700.[Abstract]
6. Loomba RS, Chandrasekar S, Sanan P, et al. Association of atrial tachyarrhythmias with atrial septal defect, Ebstein's anomaly and Fontan patients. Expert Rev Cardiovasc Ther. 2011 Jul;9(7):887-93.[Abstract]
7. DeVoe JE, Judkins DZ, Woods L. What is the best approach to the evaluation of resting tachycardia in an adult? J Fam Pract. 2007 Jan;56(1):59-61.[Abstract]
8. Thavendiranathan P, Bagai A, Khoo C, et al. Does this patient with palpitations have a cardiac arrhythmia? JAMA. 2009 Nov 18;302(19):2135-43.[Abstract]
9. Hanrahan JP, Grogan DR, Baumgartner RA, et al. Arrhythmias in patients with chronic obstructive pulmonary disease (COPD): occurrence frequency and the effect of treatment with the inhaled long-acting beta2-agonists arformoterol and salmeterol. Medicine (Baltimore). 2008 Nov;87(6):319-28.[Abstract]
10. Gerstenfeld EP, Marchlinski FE. Mapping and ablation of left atrial tachycardias occurring after atrial fibrillation ablation. Heart Rhythm. 2007 Mar;4(suppl 3):S65-72.[Abstract]
11. Chauhan VS, Krahn GJ, Skanes AC, et al. Supraventricular tachycardia. Med Clin North Am. 2001 Mar;85(2):193-223, ix.[Abstract]
12. Brugada J, Katritsis DG, Arbelo E, et al. 2019 ESC guidelines for the management of patients with supraventricular tachycardia. The Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J. 2020 Feb 1;41(5):655-720.[Abstract][Full Text]
13. Fox DJ, Tischenko A, Krahn AD, et al. Supraventricular tachycardia: diagnosis and management. Mayo Clin Proc. 2008 Dec;83(12):1400-11.[Abstract]
14. Innes JA. Review article: adenosine use in the emergency department. Emerg Med Australas. 2008 Jun;20(3):209-15.[Abstract]
15. Engelstein ED, Lippman N, Stein KM, et al. Mechanism-specific effects of adenosine on atrial tachycardia. Circulation. 1994 Jun;89(6):2645-54.[Abstract]
16. Vecht JA, Saso S, Rao C, et al. Atrial septal defect closure is associated with a reduced prevalence of atrial tachyarrhythmia in the short to medium term: a systematic review and meta-analysis. Heart. 2010 Nov;96(22):1789-97.[Abstract]
17. Pichon-Riviere A, Augustovski F, Garcia Marti S, et al. Cryoablation in cardiac arrhythmias in pediatric patients. Ciudad de Buenos Aires: Institute for Clinical Effectiveness and Health Policy (IECS); 2008.
18. Antman EM, Wenger TL, Butler VP Jr, et al. Treatment of 150 cases of life-threatening digitalis intoxication with digoxin-specific Fab antibody fragments: final report of a multicenter study. Circulation. 1990 Jun;81(6):1744-52.[Abstract]
19. Perry J, Fenrich AL, Hulse JE, et al. Pediatric use of amiodarone: efficacy and safety in critically ill patients from a multicenter protocol. J Am Coll Cardiol. 1996 Apr;27(5):1246-50.[Abstract]
20. Tracy CM, Epstein AE, Darbar D, et al. 2012 ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. Circulation. 2012 Oct 2;126(14):1784-800.[Abstract][Full Text]
21. Nerheim P, Birger-Botkin S, Piracha L, et al. Heart failure and sudden death in patients with tachycardia-induced cardiomyopathy and recurrent tachycardia. Circulation. 2004 Jul 20;110(3):247-52.[Abstract]
Referenced Articles
Guidelines
Diagnostic
Summary
These guidelines summarize the management of patients with supraventricular arrhythmias with recommendations for diagnostic procedures, as well as indications for antiarrhythmic drugs and/or nonpharmacologic treatments.Published by
American College of Cardiology; American Heart Association Task Force on Clinical Practice Guidelines; Heart Rhythm Society
Published
2015
Summary
Provides recommendations on the diagnosis and assessment of adults with supraventricular tachycardia.Published by
European Society of Cardiology (ESC)
Published
2019
Treatment
Summary
These guidelines have several algorithms for the management of supraventricular arrhythmias.Published by
American College of Cardiology; American Heart Association Task Force on Clinical Practice Guidelines; Heart Rhythm Society
Published
2015
Summary
Updated evidence-based guidelines providing recommendations for the implantation of cardiac pacemakers and antiarrhythmia devices.Published by
American College of Cardiology; American Heart Association; Heart Rhythm Society
Published
2012
Summary
Provides recommendations on the management of adults with supraventricular tachycardia.Published by
European Society of Cardiology
Published
2019