Andrade JG, Verma A, Mitchell LB, et al; CCS Atrial Fibrillation Guidelines Committee. 2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol. 2018 Nov;34(11):1371-1392. doi: 10.1016/j.cjca.2018.08.026. PubMed PMID: 30404743.
January CT, Wann LS, Alpert JS, et al; ACC/AHA Task Force Members. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014 Dec 2;130(23):e199-267. doi: 10.1161/CIR.0000000000000041. Epub 2014 Mar 28. Erratum in: Circulation. 2014 Dec 2;130(23):e272-4. PubMed PMID: 24682347; PubMed Central PMCID: PMC4676081.
Priori SG, Wilde AA, Horie M, et al. HRS/EHRA/APHRS expert consensus statement on the diagnosis and management of patients with inherited primary arrhythmia syndromes: document endorsed by HRS, EHRA, and APHRS in May 2013 and by ACCF, AHA, PACES, and AEPC in June 2013. Heart Rhythm. 2013 Dec;10(12):1932-63. doi: 10.1016/j.hrthm.2013.05.014. Epub 2013 Aug 30. Review. PubMed PMID: 24011539.
Brignole M, Auricchio A, Baron-Esquivias G, et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J. 2013 Aug;34(29):2281-329. doi: 10.1093/eurheartj/eht150. Epub 2013 Jun 24. PubMed PMID: 23801822.
American College of Cardiology Foundation; American Heart Association; European Society of Cardiology; Heart Rhythm Society, Wann LS, Curtis AB, Ellenbogen KA, et al. Management of patients with atrial fibrillation (compilation of 2006 ACCF/AHA/ESC and 2011 ACCF/AHA/HRS recommendations): a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation. 2013 May 7;127(18):1916-26. doi: 10.1161/CIR.0b013e318290826d. Epub 2013 Apr 1. PubMed PMID: 23545139.
Camm AJ, Lip GY, De Caterina R, et al; ESC Committee for Practice Guidelines (CPG). 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012 Nov;33(21):2719-47. doi: 10.1093/eurheartj/ehs253. Epub 2012 Aug 24. Erratum in: Eur Heart J. 2013 Mar;34(10):790. Eur Heart J. 2013 Sep;34(36):2850-1. PubMed PMID: 22922413.
Tracy CM, Epstein AE, Darbar D, et al; American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines; Heart Rhythm Society. 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 and the Heart Rhythm Society. [corrected]. Circulation. 2012 Oct 2;126(14):1784-800. doi: 10.1161/CIR.0b013e3182618569. Epub 2012 Sep 10. Erratum in: Circulation. 2013 Jan 22;127(3):e357-9. Heart Rhythm Society [added]. PubMed PMID: 22965336.
Pediatric and Congenital Electrophysiology Society (PACES); Heart Rhythm Society (HRS); American College of Cardiology Foundation (ACCF); American Heart Association (AHA); American Academy of Pediatrics (AAP); Canadian Heart Rhythm Society (CHRS), Cohen MI, Triedman JK, Cannon BC, et al. PACES/HRS expert consensus statement on the management of the asymptomatic young patient with a Wolff-Parkinson-White (WPW, ventricular preexcitation) electrocardiographic pattern: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), the American Academy of Pediatrics (AAP), and the Canadian Heart Rhythm Society (CHRS). Heart Rhythm. 2012 Jun;9(6):1006-24. doi: 10.1016/j.hrthm.2012.03.050. Epub 2012 May 10. PubMed PMID: 22579340.
European Heart Rhythm Association; European Association for Cardio-Thoracic Surgery, Camm AJ, Kirchhof P, Lip GY, et al. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010 Oct;31(19):2369-429. doi: 10.1093/eurheartj/ehq278. Epub 2010 Aug 29. Erratum in: Eur Heart J. 2011 May;32(9):1172. PubMed PMID: 20802247.
Definition, Etiology, PathogenesisTop
Atrial tachycardia (AT) is a paroxysmal or sustained tachycardia originating in the atrium outside the sinus node. AT may be divided into 2 types:
1) Focal AT: An accelerated (100-250 beats/min) regular rhythm originating in the atrium with a stable P wave morphology. It can occur in patients with or without heart disease.
2) Multifocal AT: An irregular rhythm with varying morphology of the P waves. It is commonly seen in patients with cardiac or lung disease and metabolic or electrolytic disturbances.
Clinical Features and Natural HistoryTop
Symptoms range from mild or nonexistent to severe, depending on the heart rate during tachycardia and presence of an underlying condition. AT sustained over a long period may lead to tachycardia-induced cardiomyopathy. AT does not cause thromboembolic complications but it may trigger atrial fibrillation (AF).
1. Electrocardiography (ECG): In patients with focal AT, P waves are identical and their shape depends on the location of the anatomical focus (they can also resemble sinus rhythm if coming from a close-by location). In multifocal AT the rhythm is grossly irregular and several morphologies of P waves are seen.
2. Electrophysiologic study (EPS): This is used to establish the exact location of the AT focus and to perform ablation.
Supraventricular tachycardia: Figure 3.4-2.
Narrow-QRS tachycardia: Figure 3.4-3.
Wide-QRS tachycardia: Figure 3.4-4.
Treatment is more difficult than in the case of atrioventricular nodal reentrant tachycardia and atrioventricular reentrant tachycardia. Effective management of underlying conditions is important.
1. IV beta-blockers, diltiazem, or verapamil are useful in hemodynamically stable patients.
2. Synchronized cardioversion is recommended for acute treatment in hemodynamically unstable patients.
3. Adenosine can be useful in the acute setting to either restore sinus rhythm (some atrial arrhythmias respond to adenosine) or diagnose the tachycardia mechanism. In the case of AT, atrial arrhythmia may continue during the atrioventricular block induced by adenosine, making the P waves clearly visible. It is important to record an ECG strip during adenosine administration.
1. In patients with symptomatic focal AT, catheter ablation is recommended as an alternative to pharmacologic treatment.
2. In patients with focal AT, oral beta-blockers, diltiazem, or verapamil are recommended for ongoing management.
3. Flecainide or propafenone can be effective in patients with no structural heart disease.
4. In multifocal AT catheter ablation is less effective. Oral verapamil or diltiazem are recommended in this case.