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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

1 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 ABSTRACT Supraventricular tachycardia (SVT) is a common cardiac arrhythmia; it usually presents with recurrent episodes of tachycardia. Sudden-onset, rapid palpitations characterize SVT and, in most patients, a diagnosis can be made largely from patient history. But repeated attempts at electrocardiographic documentation of the arrhythmia may be useful for precise diagnosis and differentiation. Key words: supraventricular tachycardia electrocardiography Received: November 2, 2010 Revision Received: February 23, 2011 Accepted: March 30, 2011 Correspondence: Hong-Euy Lim, MD, PhD. Division of Cardiac Electrophysiology, Department of Internal Medicine, Korea University Cardiovascular Center, Korea University Guro Hospital, Korea University College of Medicine, 80, Guro-2-dong, Guro-gu, Seoul , Korea Tel: (EPS Laboratory) Fax: hongeuy@korea.ac.kr or h3lim@medimail.co.kr 23

node-independent arrhythmia Sinus tachycardia Sinus node reciprocating tachycardia Atrial tachycardia Multifocal atrial tachycardia Atrial flutter Atrial fibrillation AV;

2 Table 1. Classification of supraventricular tachycardia AV node-dependent arrhythmia AV nodal reentrant tachycardia AV reentrant tachycardia Junctional ectopic tachycardia AV node-independent arrhythmia Sinus tachycardia Sinus node reciprocating tachycardia Atrial tachycardia Multifocal atrial tachycardia Atrial flutter Atrial fibrillation AV; atrioventricular A B Figure 1. Differentiation of supraventricular tachycardia. ECG shows regular tachycardia with wide QRS complex (rate=150 bpm). P waves are negative in lead II, III and avf with 2:1 pattern (A). After adenosine 6 mg IV., ventricular rate became slower and then obvious P wave was observed (B). 24 Journal of Cardiac Arrhythmia

3 Figure 2. An ECG of atrioventricular nodal re-entrant tachycardia (AVNRT). ECG shows regular tachycardia with narrow QRS (rate=195 bpm). Retrograde P waves are seen just after QRS complexes. Pseudo S wave (red arrow) is observed in II, III and avf and pseudo R wave in V1. 25

4 Figure 3. An ECG of atrioventricular re-entrant tachycardia (AVRT). ECG shows regular tachycardia with narrow QRS (rate=234 bpm). Retrograde P waves are seen after QRS complexes. ST depression (>2.5 mm) is observed in lead V5 and V6, which reflect retrograde P wave (green arrow). 26 Journal of Cardiac Arrhythmia

Saw-tooth appearance F wave is observed in lead II, III and avf without isoelectrical line.

5 A MAIN TOPIC REVIEWS B Figure 4. An ECG of atrial flutter (AFL). The ECG shows irregular tachycardia with narrow QRS (rate=102 bpm). Saw-tooth appearance F wave is observed in lead II, III and avf without isoelectrical line. This is an example of typical AFL (A). The ECG shows regular rhythm with narrow QRS (rate=72 bpm). F wave is negative in V1 and positive in lead II, III and avf. This is an example of atypical AFL (B). 27

6 Figure 5. An ECG of atrial tachycardia (AT). This is an example of long RP tachycardia. Obvious negative P waves are observed in lead II, III, and avf. V1 neg pos/neg neg/pos iso/pos iso pos V2-4 pos CT avl R.Septum Perinodal bifid in II &/or V1 yes no neg pos yes no CT neg in all inf.leads SMA CS os LS neg in all inf.leads sinus rhythm P wave yes no yes no pos +/- TA TA RAA CS Body LPV LAA CT RPV RPV Figure 6. A P-wave algorithm constructed on the basis of findings from 130 atrial tachycardias correctly localized the focus in 93% (Courtesy by Kistler PM, et al. JACC. 2006;48: ). CS; coronary sinus, CT; crista terminalis, LAA; left atrial appendage, LPV; left pulmonary vein, LS; left septum, RPV; right pulmonary vein, SMA; superior mitral annulus, TA; tricuspid annulus 28 Journal of Cardiac Arrhythmia

7 Figure 7. An ECG of atrial fibrillation (AF). Irregularly irregular RR intervals present without obvious P wave. This is an example of atrial fibrillation. 29

8 Table 2. Characteristics of supraventricular tachycardia Type of SVT Varieties Gender dominance Adenosine A:V ratio PR/RP in AV QRS complex AVNRT Slow-fast Female Stops 1:1 PR >> RP** Narrow 2:1* AVNRT Fast-slow Female Stops 1:1 PR < RP Narrow AVNRT Slow-slow Female Stops 1:1 PR > RP Narrow AVRT Orthodromic Male Stops 1:1 PR > RP Narrow conventional AVRT Antidromic Male Stops 1:1 PR = RP Wide, maximally conventional PR < RP pre-excited AT Focal Female Stops 90 % 1:1 or higher PR < RP Narrow of episodes PR = RP PR > RP*** AT Macro-reentrant Even No effect 2 :1 NA Narrow or higher RBBB if ASD AFL CTI CCW and CW Male No effect 2:1 NA Narrow or higher AFL Non-CTI Even No effect 2:1 NA Narrow or higher AFL; atrial flutter, ASD; atrial septal defect, AT; atrial tachycardia, AVNRT; atrioventricular nodal reentrant tachycardia, AVRT; atrioventricular reentrant tachycardia, BBB; bundle branch block, CCW; counterclockwise, CTI; cavo-tricuspid isthmus, CW; clockwise, SVT; supraventricular tachycardia * 2:1 ratio in AVNRT exceptional in the clinical scenario, ** P waves during slow-fast AVNRT are either hidden within the QRS complex or visible as a continuation of the QRS mimicking terminal s waves in inferior leads or r waves in V1, *** PR > RP if concomitant drugs acting on the AV node, if associated AV nodal disease or if AV conduction over a slow AV nodal pathway. (Adopted from The ESC textbook of cardiovascular medicine) References 1. Fox DJ, Tischenko A, Krahn AD, Skanes AC, Gula LJ, Yee RK, Klein GJ. Supraventricular tachycardia: diagnosis and management. Mayo Clinic proceedings. 2008;83: Delacretaz E. Clinical practice. Supraventricular tachycardia. N 30 Journal of Cardiac Arrhythmia

9 Engl J Med. 2006;354: Camm AJ, Luscher TF, Serruys PW, European Society of Cardiology. The ESC textbook of cardiovascular medicine. 2nd ed. Oxford ; New York: Oxford University Press; Caroline M, Jonathan MK, Prediction of the atrial flutter circuit location from the surface electrocardiogram. Europace. 2008; 10: Bochoeyer A, Yang Y, Cheng J, Lee RJ, Keung EC, Marrouche NF et al. Surface electrocardiographic characteristics of right and left atrial flutter. Circulation. 2003;108: Jais P, Hocini M, Weerasoryia R, Macle L, Scavee C, Raybaud F et al. Atypical left atrial flutter. Cardiac Electrophysiol Rev. 2002;6: Peter MK, Kurt CR, Harris MH, Simon PF, Suresh S, Jitendra KV, Joseph BM, Paul BS, Jonathan MK. P-wave morphology in focal atrial tachycardia. J Am Coll Cardiol. 2006;48: MAIN TOPIC REVIEWS 31

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ºÎÁ¤¸ÆV10N³»Áö A case of atrioventricular dissociation with interference ABSTRACT Interference dissociation is one of the most interesting arrhythmias. Once thought to be a rare arrhythmia, it is now considered a very