Summary
Classification of tachyarrhythmia
- Atrial impulses are characterized by initial depolarization of the atrium, from a single focus, such as sinus tachycardia or atrial tachycardia; macro reentry around an anatomic obstacle, such as in typical atrial flutter; or from multiple wavelets of reentry, such as atrial fibrillation.
- Arrhythmias that originate at the level of the junction of the atrium and ventricle (AV node and/or proximal His bundle), such as AV nodal reentrant tachycardia or junctional ectopic tachycardia, are characterized by depolarization of the ventricle and retrograde atrial activation (if present), manifested by a retrograde P wave.
- Arrhythmias that originate from the ventricle may originate from the distal His-Purkinje system or ventricular myocardium. The site of origin within the ventricle further defines some arrhythmias within the ventricle. Examples include right ventricular outflow tract ventricular tachycardia and bundle branch reentry ventricular tachycardia. Hemodynamic stability is not a helpful factor in differentiating atrial and ventricular arrhythmias. Some cases of ventricular tachycardia may be initially well tolerated hemodynamically. Misdiagnosis and inappropriate treatment (i.e., calcium channel blockers) may have catastrophic consequences.
Epidemiology
Library
Sinus rhythm with preexcitation
Sinus rhythm with preexcitation (detail)
Atrial flutter
Atrial flutter (detail)
Right ventricular outflow tract ventricular tachycardia
Ventricular tachycardia in a patient with arrhythmogenic right ventricular cardiomyopathy
Supraventricular tachycardia with aberrancy and left bundle branch block
Rate-related left bundle branch block
Antidromic reentrant tachycardia
Artifact overlying sinus rhythm
ECG example of sinus tachycardia
Atrial fibrillation: P waves are not discernible; the ventricular (QRS complexes) rate is irregularly irregular
Atrial flutter: typical saw-tooth appearance of the flutter waves in the inferior leads (leads II, III, and aVF) indicates typical counterclockwise atrial flutter; the ventricular (QRS complexes) rate is variable
Atrial tachycardia: bursts of atrial tachycardia (10 beats in the middle section of the rhythm strip II at bottom) follows sinus complexes
Multifocal atrial tachycardia
Citations
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):e27-115.[Abstract][Full Text]
Katritsis DG, Boriani G, Cosio FG, et al. European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE). Europace. 2017 Mar 1;19(3):465-511.[Abstract][Full Text]
Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. Circulation. 2024 Jan 2;149(1):e1-156.[Abstract][Full Text]
Sheldon RS, Grubb BP 2nd, Olshansky B, et al. 2015 heart rhythm society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart Rhythm. 2015 Jun;12(6):e41-63.[Full Text]
Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2018 Sep 25;138(13):e272-391.[Abstract][Full Text]
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):e27-115.[Abstract][Full Text]
2. Katritsis DG, Boriani G, Cosio FG, et al. European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE). Europace. 2017 Mar 1;19(3):465-511.[Abstract][Full Text]
3. Bjerregaard P. Mean 24 hour heart rate, minimal heart rate and pauses in healthy subjects 40-79 years of age. Eur Heart J. 1983 Jan;4(1):44-51.[Abstract]
4. Mayuga KA, Fedorowski A, Ricci F, et al. Sinus tachycardia: a multidisciplinary expert focused review. Circ Arrhythm Electrophysiol. 2022 Sep;15(9):e007960.[Abstract][Full Text]
5. Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS guideline for the diagnosis and management of atrial fibrillation: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. Circulation. 2024 Jan 2;149(1):e1-156.[Abstract][Full Text]
6. Tsao CW, Aday AW, Almarzooq ZI, et al. Heart disease and stroke statistics-2023 update: a report from the American Heart Association. Circulation. 2023 Feb 21;147(8):e93-621.[Abstract][Full Text]
7. Chugh SS, Havmoeller R, Narayanan K, et al. Worldwide epidemiology of atrial fibrillation: a Global Burden of Disease 2010 Study. Circulation. 2014 Feb 25;129(8):837-47.[Abstract][Full Text]
8. Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001 May 9;285(18):2370-5.[Abstract][Full Text]
9. Murphy NF, Simpson CR, Jhund PS, et al. A national survey of the prevalence, incidence, primary care burden and treatment of atrial fibrillation in Scotland. Heart. 2007 May;93(5):606-12.[Abstract][Full Text]
10. Martin SS, Aday AW, Almarzooq ZI, et al. 2024 heart disease and stroke statistics: a report of US and Global Data From the American Heart Association. Circulation. 2024 Feb 20;149(8):e347-913.[Abstract][Full Text]
11. Colilla S, Crow A, Petkun W, et al. Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population. Am J Cardiol. 2013 Oct 15;112(8):1142-7.[Abstract][Full Text]
12. Krijthe BP, Kunst A, Benjamin EJ, et al. Projections on the number of individuals with atrial fibrillation in the European Union, from 2000 to 2060. Eur Heart J. 2013 Sep;34(35):2746-51.[Abstract][Full Text]
13. Granada J, Uribe W, Chyou P, et al. Incidence and predictors of atrial flutter in the general population. J Am Coll Cardiol. 2000 Dec;36(7):2242-6.[Abstract]
14. Brugada J, Katritsis DG, Arbelo E, et al. 2019 ESC Guidelines for the management of patients with supraventricular tachycardia. Eur Heart J. 2020 Feb 1;41(5):655-720.[Full Text]
15. Rehorn M, Sacks NC, Emden MR, et al. Prevalence and incidence of patients with paroxysmal supraventricular tachycardia in the United States. J Cardiovasc Electrophysiol. 2021 Aug;32(8):2199-206.[Abstract]
16. Orejarena L, Vidaillet HJ, DeStefano F, et al. Paroxysmal supraventricular tachycardia in the general population. J Am Coll Cardiol. 1998 Jan;31(1):150-7.[Abstract][Full Text]
17. Trohman RG. Supraventricular tachycardia: implications for the intensivist. Crit Care Med. 2000 Oct;28(10 Suppl):N129-35.[Abstract]
18. Brady PA, Low PA, Shen WK. Inappropriate sinus tachycardia, postural orthostatic tachycardia syndrome, and overlapping syndromes. Pacing Clin Electrophysiol. 2005 Oct;28(10):1112-21.[Abstract]
19. Lally J, Docherty MJ, MacCabe JH. Pharmacological interventions for clozapine-induced sinus tachycardia. Cochrane Database Syst Rev. 2016;(6):CD011566.[Abstract]
20. Vernino S, Bourne KM, Stiles LE, et al. Postural orthostatic tachycardia syndrome (POTS): State of the science and clinical care from a 2019 National Institutes of Health Expert Consensus Meeting - Part 1. Auton Neurosci. 2021 Nov;235:102828.[Abstract][Full Text]
21. Sheldon RS, Grubb BP 2nd, Olshansky B, et al. 2015 heart rhythm society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart Rhythm. 2015 Jun;12(6):e41-63.[Full Text]
22. Shen WK, Sheldon RS, Benditt DG, et al. 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines and the Heart Rhythm Society. Circulation. 2017 Aug 1;136(5):e25-59.[Full Text]
23. Raj SR, Guzman JC, Harvey P, et al. Canadian Cardiovascular Society position statement on postural orthostatic tachycardia syndrome (POTS) and related disorders of chronic orthostatic intolerance. Can J Cardiol. 2020 Mar;36(3):357-72.[Abstract][Full Text]
24. Steinbeck G, Hoffmann E. 'True' atrial tachycardia. Eur Heart J. 1998 May;19(Suppl E):E10-2,E48-9.[Abstract]
25. Kotadia ID, Williams SE, O'Neill M. Supraventricular tachycardia: an overview of diagnosis and management. Clin Med (Lond). 2020 Jan;20(1):43-7.[Abstract][Full Text]
26. Gillette PC, Garson AJ, Kugler JD. Wolff-Parkinson-White syndrome in children: electrophysiologic and pharmacologic characteristics. Circulation. 1979 Dec;60(7):1487-95.[Abstract][Full Text]
27. Veenhuyzen GD, Simpson CS, Abdollah H. Atrial fibrillation. CMAJ. 2004 Sep 28;171(7):755-60.[Abstract][Full Text]
28. Medicines and Healthcare products Regulatory Agency. Omega-3-acid ethyl ester medicines (Omacor/Teromeg 1000mg capsules): dose-dependent increased risk of atrial fibrillation in patients with established cardiovascular diseases or cardiovascular risk factors. Jan 2024 [internet publication].[Full Text]
29. Lombardi M, Carbone S, Del Buono MG, et al. Omega-3 fatty acids supplementation and risk of atrial fibrillation: an updated meta-analysis of randomized controlled trials. Eur Heart J Cardiovasc Pharmacother. 2021 Jul 23;7(4):e69-70.[Full Text]
30. Gencer B, Djousse L, Al-Ramady OT, et al. Effect of long-term marine ɷ-3 fatty acids supplementation on the risk of atrial fibrillation in randomized controlled trials of cardiovascular outcomes: a systematic review and meta-analysis. Circulation. 2021 Dec 21;144(25):1981-90.[Abstract][Full Text]
31. Shine KI, Kastor JA, Yurchak PM. Multifocal atrial tachycardia. Clinical and electrocardiographic features in 32 patients. N Engl J Med. 1968 Aug 15;279(7):344-9.[Abstract]
32. Iseri LT, Fairshter RD, Hardemann JL, et al. Magnesium and potassium therapy in multifocal atrial tachycardia. Am Heart J. 1985 Oct;110(4):789-94.[Abstract]
33. Deal BJ, Miller SM, Scagliotti D, et al. Ventricular tachycardia in a young population without overt heart disease. Circulation. 1986 Jun;73(6):1111-8.[Abstract][Full Text]
34. Al-Khatib SM, Stevenson WG, Ackerman MJ, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation. 2018 Sep 25;138(13):e272-391.[Abstract][Full Text]
35. Zeppenfeld K, Tfelt-Hansen J, de Riva M, et al. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J. 26 Aug 2022 [Epub ahead of print].[Abstract][Full Text]
36. de Bakker JM, van Capelle FJ, Janse MJ, et al. Reentry as a cause of ventricular tachycardia in patients with chronic ischemic heart disease: electrophysiologic and anatomic correlation. Circulation. 11988 Mar;77(3):589-606.[Abstract][Full Text]
37. Kouranos V, Sharma R. Cardiac sarcoidosis: state-of-the-art review. Heart. 2021 Oct;107(19):1591-9.
38. Nery PB, Mc Ardle BA, Redpath CJ, et al. Prevalence of cardiac sarcoidosis in patients presenting with monomorphic ventricular tachycardia. Pacing Clin Electrophysiol. 2014 Mar;37(3):364-74.[Abstract]
39. Nery PB, Beanlands RS, Nair GM, et al. Atrioventricular block as the initial manifestation of cardiac sarcoidosis in middle-aged adults. J Cardiovasc Electrophysiol. 2014 Aug;25(8):875-81.[Abstract]
40. Baughman RP, Teirstein AS, Judson MA, et al. Clinical characteristics of patients in a case control study of sarcoidosis. Am J Respir Crit Care Med. 2001 Nov 15;164(10 pt 1):1885-9.[Abstract][Full Text]
41. Chow KL, O'Donnell JL, Crozier I. Prevalence, incidence and survival outcomes of cardiac sarcoidosis in the South Island, New Zealand. Int J Cardiol. 2022 Jun 15;357:128-33.[Abstract]
42. Maizels L, Mansour M, Abu-Much A, et al. Prevalence of cardiac sarcoidosis in middle-aged adults diagnosed with high-grade atrioventricular block. Am J Med. 2024 Apr;137(4):358-65.[Abstract]
43. Passman R, Kadish A. Polymorphic ventricular tachycardia, long Q-T syndrome, and torsades de pointes. Med Clin North Am. 2001 Mar;85(2):321-41.[Abstract]
44. The Cardiac Society of Australia and New Zealand. Guidelines for the diagnosis and management of catecholaminergic polymorphic ventricular tachycardia. Nov 2016 [internet publication].[Full Text]
45. Tisdale JE, Chung MK, Campbell KB, et al. Drug-induced arrhythmias: a scientific statement from the American Heart Association. Circulation. 2020 Oct 13;142(15):e214-33.[Abstract][Full Text]
46. Goldberger JJ, Cain ME, Hohnloser SH, et al. American Heart Association/American College of Cardiology Foundation/Heart Rhythm Society scientific statement on noninvasive risk stratification techniques for identifying patients at risk for sudden cardiac death: a scientific statement from the American Heart Association Council on Clinical Cardiology Committee on Electrocardiography and Arrhythmias and Council on Epidemiology and Prevention. Circulation. 2008 Sep 30;118(14):1497-518.[Abstract][Full Text]
47. Winkle RA, Mead RH, Ruder MA, et al. Effect of duration of ventricular fibrillation on defibrillation efficacy in humans. Circulation. 1990 May;81(5):1477-81.[Abstract][Full Text]
48. De Maio VJ, Stiell IG, Wells GA, et al. Optimal defibrillation response intervals for maximum out-of-hospital cardiac arrest survival rates. Ann Emerg Med. 2003 Aug;42(2):242-50.[Abstract]
49. Rea TD, Eisenberg MS, Becker LJ, et al. Temporal trends in sudden cardiac arrest: a 25-year emergency medical services perspective. Circulation. 2003 Jun 10;107(22):2780-5.[Abstract][Full Text]
50. Seidl K, Rameken M, Breunung S, et al. Diagnostic assessment of recurrent unexplained syncope with a new subcutaneously implantable loop recorder. Reveal-Investigators. Europace. 2000 Jul;2(3):256-62.[Abstract][Full Text]
51. Goldberger ZD, Rho RW, Page RL. Approach to the diagnosis and initial management of the stable adult patient with a wide complex tachycardia. Am J Cardiol. 2008 May 15;101(10):1456-66.[Abstract]
52. Brignole M, Sutton R, Menozzi C, et al. Early application of an implantable loop recorder allows effective specific therapy in patients with recurrent suspected neurally mediated syncope. Eur Heart J. 2006 May;27(9):1085-92.[Abstract][Full Text]
53. Krahn AD, Klein GJ, Yee R, et al. The high cost of syncope: cost implications of a new insertable loop recorder in the investigation of recurrent syncope. Am Heart J. 1999 May;137(5):870-7.[Abstract]
54. Svennberg E, Tjong F, Goette A, et al. How to use digital devices to detect and manage arrhythmias: an EHRA practical guide. Europace. 2022 Jul 15;24(6):979-1005.[Full Text]
55. Bouzid Z, Al-Zaiti SS, Bond R, et al. Remote and wearable ECG devices with diagnostic abilities in adults: a state-of-the-science scoping review. Heart Rhythm. 2022 Jul;19(7):1192-201.[Abstract][Full Text]
56. Tooley JE, Perez MV. Role of digital health in detection and management of atrial fibrillation. Heart. 2022 May 12;108(11):834-9.[Abstract]
57. National Institute for Health and Care Excellence. Atrial fibrillation: diagnosis and management. Jun 2021 [internet publication].[Full Text]
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