Evaluation and Initial Treatment of Supraventricular Tachycardia N Engl J Med 2012;367:1438-48.

1. CLINICAL PRACTICE
Evaluation and Initial Treatment
of Supraventricular Tachycardia
2012;367:1438-48.

3. Atrial fibrillation (AF)
Underlying causes Response to Adenosine
Cardiac disease, pulmonary Termination of tachycardia
disease, pulmonary
embolism, hyperthyroidism, Atiral Activity and P:QRS
postoperative Relationship
Fibrillatory waves, no
Regularity relationship to QRS
Irregular
ECG
Rate (bpm)
100-220
Onset
Sudden or gradual (if in
chronic AF)

4. Multifocal atrial tachycardia
(MAT)
Underlying causes Response to Adenosine
Pulmonary disease, None
theophylline therapy
Atiral Activity and
Regularity P:QRS Relationship
Irregular Changing P morphologic
features before QRS
Rate (bpm)
100-150 ECG
Onset
Gradual

5. Frequent atrial premature
contractions
Underlying causes Response to Adenosine
Caffeine, stimulants None
Regularity Atiral Activity and
Irregular P:QRS Relationship
P before QRS
Rate (bpm)
100-150 ECG
Onset
Gradual

6. Sinus tachycardia
Underlying causes Response to Adenosine
Sepsis, hypovolemia, Transient slowing
anemia, pulmonary
embolism, pain, fear, fright, Atiral Activity and P:QRS
exertion, myocardial Relationship
ischemia, hyperthyroidism, P before QRS
heart failure
ECG
Regularity
Regular
Rate (bpm)
220 minus the patient’s age
Onset
Gradual

7. Atrial flutter (AFL)
Underlying causes Response to Adenosine
Cardiac disease Transient slowing of
ventricular rate
Regularity
Regular (occasionally Atiral Activity and
irregular if variable AV P:QRS Relationship
conduction) Flutter wave, usually 2:1
Rate (bpm) ECG
150
Onset
Sudden

8. AV nodal reentrant tachycardia
(AVNRT)
Underlying causes Response to Adenosine
Non Termination of tachycardia
Regularity Atiral Activity and
Regular P:QRS Relationship
Rate (bpm) No apparent atrial activity
or R’ at termination of QRS
150-250
ECG
Onset
Sudden

9. AV reciprocating tachycardia
(AVRT)
Underlying causes Response to Adenosine
Rarely, Ebstein’s anomaly Termination of tachycardia
Regularity ECG
Regular In narrow complex,
P after QRS
Rate (bpm)
150-250 In wide complex,
P rarely observed
Onset
Sudden In irregular rhythm
(Afib), no apparent
P wave

10. Atrial tachycardia (AT)
Underlying causes Response to Adenosine
Cardiac disease, Termination of tachycardia
pulmonary disease
Atiral Activity and
Regularity P:QRS Relationship
Regular P before QRS
Rate (bpm) ECG
150-250
Onset
Sudden

11. Irregular
RegularSupraventricularTachycardias SupraventricularTachycardias

12. Differential Diagnosis of
Supraventricular Tachycardias
The initial differential diagnosis of supraventricular
tachycardias should focus on the ventricular response
characteristics of regularity, rate, and rapidity of onset,
not on the atrial depolarization from the ECG.
The regular supraventricular tachycardias include
sinus tachycardia, atrial flutter, atrioventricular nodal
reentrant tachycardia, atrioventricular reciprocating
tachycardia, and atrial tachycardia.
The irregular supraventricular tachycardias are atrial
fibrillation, atrial flutter with variable atrioventricular
block, and multifocal atrial tachycardia; multiple atrial
premature contractions can cause a similar
presentation.

13. Differential Diagnosis of
Supraventricular Tachycardias
Sudden onset and termination are
characteristic of acute atrial fibrillation and
atrial flutter, atrioventricular nodal reentrant
tachycardia, atrioventricular reciprocating
tachycardia, and atrial tachycardia.
Gradual onset and recession occur with sinus
tachycardia, chronic atrial fibrillation and atrial
flutter, multifocal atrial tachycardia, and atrial
premature contractions.

14. Differential Diagnosis of
Supraventricular Tachycardias
Adenosine blocks the atrioventricular node and is
useful in distinguishing among supraventricular
tachycardias but should not be given in the case of
irregular wide-complex tachycardias, since it may
render these rhythms unstable.
After administration of adenosine, slowing of the
heart rate is consistent with a diagnosis of sinus
tachycardia, atrial tachycardia, atrial fibrillation, or
atrial flutter, whereas termination of tachycardia
points to atrioventricular nodal reentrant
tachycardia, atrioventricular reciprocating
tachycardia, and some atrial tachycardias.

15. Narrow-complex tachycardia
Regular rhythm Irregular rhythm
Sudden onset Gradual onset HR <150 bpm HR •≧150 bpm
Adenosine ST AF, MAT, NSR, AF, AFL with
or ST with APCs variable block
Termination No termination Treat underlying
cause Rate control with β-
blocker, verapamil,
diltiazem;
AVNRT, AT, AFL (ST,
if unstable condition,
AVRT, AT less frequently)
cardioversion,
procainamide,
Differential Diagnosis and Treatment ibutilde
of Narrow-Complex Tachycardias.

16. Wide-complex tachycardia
Underlying heart disease
No Yes
Irregular rhythm Regular rhythm
Unstable condition Stable condition Stable condition Unstable condition
Polymorphic AF with AF with aberrancy Adenosine
VT, VF WPW or AF with benign
WPW
Cardioversion–defibrillation Termination No termination VT
Differential Diagnosis and SVT with Cardioversion; IV
Treatment of Wide- aberrancy, procainamide,
AVRT (WPW), sotalol, lidocaine,
Complex Tachycardias.
idiopathic VT or amiodarone