REVIEW ARTICLES International Journal of Arrhythmia 2017;18(1):43-47 doi: 심실상빈맥의감별진단 장성원 가톨릭대학교의과대학내과학교

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REVIEW ARTICLES doi: http://dx.doi.org/10.18501/arrhythmia.2017.006 심실상빈맥의감별진단 장성원 가톨릭대학교의과대학내과학교실 Sung-Won Jang, MD Division of Cardiology, St.

1 REVIEW ARTICLES doi: 심실상빈맥의감별진단 장성원 가톨릭대학교의과대학내과학교실 Sung-Won Jang, MD Division of Cardiology, St. Paul s Hospital, Department of Internal Medicine, The Catholic University of Korea, Seoul, Republic of Korea Received: May 16, 2016 Revision Received: February 7, 2017 Accepted: February 7, 2017 Correspondence: Sung-Won Jang, MD, PhD St. Paul s Hospital, The Catholic University of Korea, 180 Wangsan-ro, Dongdaemun-gu, Seoul 02559, Republic of Korea Tel: Fax: sungwon.jang@catholic.ac.kr Copyright 2017 The Official Journal of Korean Heart Rhythm Society Editorial Board & MMK Co., Ltd. ABSTRACT Supraventricular tachycardia (SVT) refers to a heterogeneous group of arrhythmias localized within the upper part of the heart (the His bundle or above). In general, the term SVT does not include atrial fibrillation. Common forms of SVT include atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, focal atrial tachycardia, and atrial flutter. Other, less common arrhythmias also fall under the category of SVT, including inappropriate sinus tachycardia and junctional reentrant/ectopic tachycardia. Paroxysmal supraventricular tachycardia refers to AVNRT and AVRT. SVTs can be identified and classified by clinical manifestation/physical examination, ECG, and/or electrophysiologic analysis. Key Words: Supraventricular Tachycardia Electrocardiography 서론 증상및진찰소견 심실상빈맥은용어상으로는심방과방실접합부에서기인하는빈맥을모두일컫지만, 일반적으로심방세동은포함하지않는다. 주로방실결절회귀성빈맥, 방실회귀성빈맥, 심방빈맥, 심방조동이흔하고, 그외동결절이나접합부에서기인하는회귀또는이소성빈맥등이포함된다. 방실결절회귀성빈맥과방실회귀성빈맥은발작성심실상빈맥으로부른다. 심실상빈맥은크게진찰소견, 심전도, 심장전기생리검사를통해감별할수있다. 문진과진찰만으로심실상빈맥을감별할수는없지만, 발작성심실상빈맥으로분류하는방실결절회귀성빈맥과방실회귀빈맥은회귀회로가방실결절을포함하기때문에이를억제하는발살바수기 (Valsalva maneuver) 로빈맥이종료되는특징이있다. 발살바수기로환자가스스로터득하여아랫배에힘을주거나쪼그려앉았을때빈맥이종료된다면발작성심실상빈맥을먼저고려한다. 방실결절회귀성빈맥은기전과연관된특징적인소견이있다. 방실결절회귀성빈맥은회귀회로가방실결절안에있고 43

2 전기자극이심방과심실에동시에전달되어삼첨판이닫힌상태에서우심방이수축한다. 이압력이경정맥으로전달되어캐논 A파 (cannon A-wave) 가관찰되며, 경정맥이규칙적으로불룩거리며튀어나와개구리사인 (frog sign) 이라고도한다. 1 이렇게우심방의압력이증가하면심방나트륨이뇨펩티드를분비하여소변량이증가하기도한다. 이러한소견은방실회귀성빈맥보다는방실결절회귀성빈맥일가능성을시사하나절대적이지는않다. 또한평소에심방세동이있던환자가규칙적인리듬의빈맥을보인다면먼저심방조동을의심한다. 심전도소견 : 넓은 QRS 빈맥의감별진단 넓은 QRS 빈맥 (QRS 간격 >120 ms) 은심실빈맥을우선생각하지만, 심실상빈맥이비정상적으로전도되면서 QRS가넓게보일수가있다. 심실상빈맥이비정상적으로전도되는경우는맥박이빨라지면서발생하는편위전도, 원래각차단이있었던경우, 그리고심실조기흥분 (pre-excitation) 등이있다. 이를감별하는방법을 Table 1에요약하였다. 넓은 QRS 빈맥이규칙적이고혈역학적으로안정적일때에국한해서빈맥이종료되는지알아보기위해 adenosine을사용할수있다. 2 하지만심실빈맥을심실상빈맥으로오인할경우심각한위험을초래할수있으므로감별이명확하지않을때는심실빈맥에준해서치료하는것이바람직하다. 특히심근경색으로인한허혈성심근병증이나확장또는비대심근병증등의구조적인심질환이있는경우는심실빈맥을우선적으로고려해야한다. 심전도소견 : 좁은 QRS 빈맥의감별진단 좁은 QRS 빈맥을감별하는알고리듬은 figure 1에요약하였다. 우선빈맥의규칙성을본다. 빈맥이불규칙하다면심방세동, 다소성심방빈맥, 또는심방빈맥 / 조동에서방실전도가 1:1이아닌경우등이해당된다. 빈맥이규칙적이라면 P파를찾는다. 뚜렷한 P파가관찰되지않는다면 RP 간격이매우짧아 P파가 QRS 안에숨어있는방실결절회귀성빈맥일가능성이높다. 때로는역방향으로전도되는 P파가 II, III, avf의 QRS 끝에살짝나타나는데이를가성 S파 (pseudo S wave) 라고부른다. V 1 유도에서는양성으로관찰되어가성 R (pseudo R ) 로부른다. 심전도상 P 파가 QRS보다많다면심방빈맥 / 조동을시사한다. 빈맥의근원은접합부위쪽에있고접합부는지나가는통로로만이용되는데맥박이매우빠른경우방실결절에서걸러지기때문이다. P파가 QRS와 1:1로대응될때는 RP와 PR 간격을비교한다. RP 간격이 PR 간격보다짧으면방실결절회귀성빈맥또는방실회귀성빈맥일가능성이높다. 방실결절회귀빈맥은회귀회로가방실결절내에있고, 심방과심실에동시에전기적인자극을보내기때문에 RP 간격이매우짧다. Table 1. ECG criteria to differentiate ventricular tachycardia from supraventricular tachycardia in wide-complex tachycardia Findings or leads on ECG assessed QRS complex in leads V 1 -V 6 (Brugada criteria) 3 QRS complex in avr (Vereckei algorithm) 4 AV dissociation Concordance R-wave peak time in lead II 5 Interpretation Lack of any R-S complexes implies VT R-S interval (onset of R wave to nadir of S wave) > 100 ms in any precordial lead implies VT Presence of initial R wave implies VT Initial R or Q wave >40ms implies VT Presence of a notch on the descending limb at the onset of a predominantly negative QRS implies VT Presence of AV dissociation (with ventricular rate faster than atrial rate) of fusion complexes implies VT QRS complexes in precordial leads all positive or all negative implies VT R-wave peak time 50 ms suggests VT Modified from the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia. 6 AV, atrioventricular; ECG, electrocardiogram; VT, ventricular tachycardia 44

3 따라서 RP 간격이 90 ms 이하일경우는방실회귀성빈맥보다는방실결절회귀성빈맥을시사한다 (Figure 2A). 방실회귀성빈맥도심실에서부전도로를거쳐심방으로가는시간이심방에서방실결절을지나심실로가는시간보다짧기때문에일반적으로 RP 간격이 PR 간격보다짧다 (Figure 2B). RP 간격이 PR 간격보다길면심방빈맥, 영구형접합부회귀빈맥등을시사한다. 심방빈맥은동결절이아닌특정한심방부위에서빈맥이형성되어방실결절을타고내려가는빈맥이다. 발생하는부위에따라 P파의모양이달라지고, 일반적으로 RP 간격이 PR 간격보다길다 (Figure 2C). 영구형접합부회귀빈맥은방실회귀빈맥의변형된형태로느리게전도되는부전도로가주로심방중격후방에있어회귀고리를형성하는데, 전도속도가느려 RP 간격이 PR 간격보다길게나타난다. 이런여러가지심실상빈맥에는예외가있어서비전형방실결절회귀성빈맥은 RP 간격이 90 ms 이상이거나오히려 PR 간격보다길수있고심방빈맥도아주빠른경우에는방실결절에서전도속도가느려지면서 RP 간격이 PR 간격보다짧을수있다. 방실차단을유발하는방법 좁은 QRS 빈맥을감별할때방실차단을유발하는방법은매우유용하다. 방실차단을유발하는방법은앞에언급한발살바수기외에경정맥동마사지 (carotid sinus massage) 와 adenosine, verapamil 등의약물사용이있다. 회귀회로에방실결절이필수적인방실결절회귀성빈맥과방실회귀성빈맥은이방법으로빈맥이종료된다. 심방조동은방실차단이일어나면서조동파가뚜렷이관찰되어쉽게감별할수있다. 심방빈맥은방실차단이되면 P파만지속적으로관찰된다. 심장전기생리검사 심장전기생리검사는심실상빈맥을진단하는데절대적인정보를제공한다. 빈맥이발생하였을때심방이흥분하는순서 (atrial activation sequence) 는어떤지관찰하여감별진단목록을작성한후, 심방또는심실자극 (pacing maneuver) 에대한반응을분석하여정확한진단을내리게된다. 주로감별대상이되는빈맥은방실결절빈맥과 Regular tachycardia Visible P waves Atrial rate greater than ventricular rate Atrial flutter or Atrial tachycardia RP <90ms AVNRT RP interval short (RP<PR) Atrial fibrillation. Atrial tachycardia/flutter with variable AV conduction, MAT AVNRT or other mechanism with P waves not identified Atrial tachycardia, PJRT, or Atypical AVNRT AVRT, Atypical AVNRT, or Atrial tachycardia Figure 1. Differential diagnosis for adult narrow QRS tachycardia Modified from the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia. AV, atrioventricular; AVNRT, atrioventricular nodal reentrant tachycardia; AVRT, atrioventricular reentrant tachycardia; MAT, multifocal atrial tachycardia; PJRT, permanent junctional reciprocating tachycardia 45

A B C Figure 2. Differential diagnosis of supraventricular tachycardia using RP interval. A, B: Short RP tachycardia. The red arrows indicate P waves.

The recordings of A, B, and C are atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, and atrial tachycardia, respectively.

심실조기수축 (ventricular premature depolarization, VPD) 은방실회귀성빈맥을감별하는데매우유용하다. 빈맥이유지되는상황에서히스속이불응기일때 VPD를주면, 전기자극이히스를통해서는올라갈수없기때문에방실결절회귀성빈맥이나심방빈맥은영향을받지않는다.

4 A B C Figure 2. Differential diagnosis of supraventricular tachycardia using RP interval. A, B: Short RP tachycardia. The red arrows indicate P waves. The RP interval in A is shorter (<90ms) than that in B. C: Long RP tachycardia. The red arrow indicates P wave. The recordings of A, B, and C are atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, and atrial tachycardia, respectively. 심방중격에부전도로가있는방실회귀빈맥그리고심방중격에서기인하는심방빈맥인데, 이세빈맥은 atrial activation sequence가비슷하기때문이다. 감별진단을위한 pacing maneuver에는여러가지가있으나여기서는빈맥이유발되었을때유용한기본적인두가지만소개한다. 심실조기수축 (ventricular premature depolarization, VPD) 은방실회귀성빈맥을감별하는데매우유용하다. 빈맥이유지되는상황에서히스속이불응기일때 VPD를주면, 전기자극이히스를통해서는올라갈수없기때문에방실결절회귀성빈맥이나심방빈맥은영향을받지않는다. 방실회귀성빈맥은부전도로를통해심방이조기흥분되면서 (atrial prexcitation) 이후의빈맥도당겨지는결과를초래한다. 7,8 빈맥일때심실을연속적으로자극하여 (overdrive ventricular pacing) 심방으로자극이전달되도록한다음, 자극을중단하여원래빈맥으로돌아갈때 V-A-V 양상을보이면방실결절회귀성빈맥또는방실회귀성빈맥이며, V-A-A-V 로나타나면심방빈맥이다. 회복양상이 V-A-V 로나타날경우원래빈맥으로회복되는간격 (post pacing interval, PPI) 은방실결절회귀성빈맥이방실회귀성빈맥보다길다. 방실결절회귀성빈맥은원래빈맥으로 회복될때 slow pathway를통해심실로전도되기때문이다. PPI는빈맥의속도에영향을받는다. PPI에서 tachycardia cycle length를뺀값을기준으로 115 ms 이하이면방실회귀성빈맥, 초과하면방실결절회귀성빈맥일가능성이높다. 9 결론 심실상빈맥은여러부정맥이포함된종합적인질병군으로임상적으로흔하게관찰된다. 자세한진찰과심전도로감별할수있으며, 심장전기생리검사로확진이가능하고도자절제술을통해완치할수있는빈맥이다. 심전도를판독할때좁은 QRS 빈맥은 RR 간격의규칙성과 P파의유무, RP 간격에유의한다. 또한심실상빈맥이지만넓은 QRS 빈맥을보이는경우가있으므로이에대해서도잘숙지하는것이중요하다. References 1) Contreras-Valdes FM, Josephson ME. IMAGES IN CLINICAL MEDICINE. "Frog Sign" in Atrioventricular dal Reentrant Tachycardia. N Engl J Med. 2016;374:e17. 46

5 2) Neumar RW, Otto CW, Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD, Hess EP, Tang W, Davis D, Sinz E, Morrison LJ. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S729-S767. 3) Brugada P, Brugada J, Mont L, Smeets J, Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation. 1991;83: ) Vereckei A, Duray G, Szenasi G, Altemose GT, Miller JM. New algorithm using only lead avr for differential diagnosis of wide QRS complex tachycardia. Heart Rhythm. 2008;5: ) Pava LF, Perafan P, Badiel M, Arango JJ, Mont L, Morillo CA, Brugada J. R-wave peak time at DII: a new criterion for differentiating between wide complex QRS tachycardias. Heart Rhythm. 2010;7: ) Page RL, Joglar JA, Caldwell MA, Calkins H, Conti JB, Deal BJ, Estes NA, 3rd, Field ME, Goldberger ZD, Hammill SC, Indik JH, Lindsay BD, Olshansky B, Russo AM, Shen WK, Tracy CM, Al-Khatib SM, Evidence Review Committee Chairdouble d 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. Circulation. 2016;133:e506-e574. 7) Sellers TD, Jr., Gallagher JJ, Cope GD, Tonkin AM, Wallace AG. Retrograde atrial preexcitation following premature ventricular beats during reciprocating tachycardia in the Wolff-Parkinson- White syndrome. Eur J Cardiol. 1976;4: ) Miles WM, Yee R, Klein GJ, Zipes DP, Prystowsky EN. The preexcitation index: an aid in determining the mechanism of supraventricular tachycardia and localizing accessory pathways. Circulation. 1986;74: ) Michaud GF, Tada H, Chough S, Baker R, Wasmer K, Sticherling C, Oral H, Pelosi F, Jr., Knight BP, Strickberger SA, Morady F. Differentiation of atypical atrioventricular node re-entrant tachycardia from orthodromic reciprocating tachycardia using a septal accessory pathway by the response to ventricular pacing. J Am Coll Cardiol. 2001;38:

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ePapyrus PDF Document MAIN TOPIC REVIEWS Hong-Euy Lim, MD, PhD Division of Cardiology, Korea University Guro Hospital, Seoul, Republic of Korea Surface electrocardiography of supraventricular tachycardia - differential diagnosis