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A 56 year old year old woman presents to the Emergency Department with a referral from her General
Practitioner for assessment and management of severe tachycardia and possible myocardial
infarction following a sudden onset of palpitations. Objectively she was found to have a regular
tachycardia with no overt signs of cardiovascular compromise
Case Study
The patient described experiencing the sudden onset of palpitations whilst cleaning at 10:30am that
morning. She stated that the palpitations came on without warning and had not gone away after she
ceased cleaning to lie down they were regular and extremely fast. There were no associated
symptoms of shortness of breath, dizziness or chest pain. Five hours later, upon her presentation to
the Emergency Department, the rapid heart rate is still continuing.
She describes to you a ve year history of occasional episodes of suddenly increased heart rate, but
in all cases, they self-resolved within one minute and she did not seek medical investigation or
treatment.
On examination in the emergency department, her heart rate is 160bpm and regular, RR 20bpm and
BP 134/75. She was apyrexial and saturating at 97% on room air. Cardiovascular and respiratory
examination revealed no abnormalities aside from the tachycardia.
Her ECG on arrival is shown below:
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On the history, examination and ECG ndings, the patient was diagnosed with Fast-Slow AVNRT
(Uncommon Atrioventricular Nodal Reentrant Tachycardia) and successfully treated with 6mg of
adenosine.
What is AVNRT?
Atrioventricular Nodal Reentrant Tachycardia is a type of supraventricular tachycardia (ie it originates
above the level of the Bundle of His) and is the commonest cause of palpitations in patients with hearts
exhibiting no structurally abnormality.
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The descriptive terminology regarding AVNRT classication can be confusingand I am still confused!
Slow-Fast AVNRT (Common AVNRT)
Accounts for 80-90% of AVNRT
Associated with Slow AV nodal pathway for anterograde conduction and Fast AV nodal pathway for
retrograde conduction.
The retrograde P wave is obscured in the corresponding QRS or occurs at the end of the QRS
complex as pseudo r or S waves
ECG:
P waves are often hidden being embedded in the QRS complexes.
Pseudo r wave may be seen in V1
Pseudo S waves may be seen in leads II, III or aVF.
In most cases this results in a typical SVT appearance with absent P waves and tachycardia
AVNRT Slow-Fast
Cardiac rhythm strips demonstrating (top) sinus rhythm and (bottom) paroxysmal supraventricular
tachycardia. The P wave is seen as a pseudo-R wave (circled in bottom strip) in lead V1during
tachycardia. By contrast, the pseudo-R wave is not seen during sinus rhythm (it is absent from circled
area in top strip). This very short ventriculoatrial time is frequently seen in typical Slow-Fast
Atrioventricular Nodal Reentrant Tachycardia.
Fast-Slow AVNRT (Uncommon AVNRT)
Accounts for 10% of AVNRT
Associated with Fast AV nodal pathway for anterograde conduction and Slow AV nodal pathway for
retrograde conduction.
The retrograde P wave appears after the corresponding QRS
ECG
QRS -P-T complexes
P waves are visible between the QRS and T wave
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Left Panel: Anterograde conduction from the atrium (ATR) to the ventricle (VTR) over both slow and
fast pathways. The ventricle is activated initially in sinus rhythm by the fast pathway.
Centre Panel: The effect of a premature atrial complex (PAC). Although the fast pathway conducts
rapidly, it repolarizes slowly. In this hypothetical scenario, the fast pathway is refractory to the PAC,
allowing the PAC to proceed via the slow pathway, which has a shorter refractory period.
Right Panel: Anterograde conduction of the PAC occurs via the slow pathway, with subsequent
recovery of the fast pathway. These conditions allow retrograde conduction into the atrium via the
fast pathway, thereby creating the rst beat of typical slow-fast atrioventricular nodal reentrant
tachycardia.
Investigations
The ECG will typically show a tachycardia of 140-280 bpm with normal and regular QRS complexes. There
will be either
No visible P-waves (hidden within the QRS complex) or
P-waves immediately before the QRS or
P-waves immediately after the QRS complex
For recurrent episodes of palpitations, a Holter monitor and EPS may be useful in identifying rhythms
typical of AVNRT. An echocardiogram may be useful in evaluating for structural heart disease and
electrophysiological studies may be necessary if considering ablative therapy. Blood tests that may be
appropriate in patients experiencing palpitations include cardiac markers (to investigate for myocardial
infarction), urea and electrolytes (to identify imbalances in potassium, magnesium or calcium) or thyroid
function tests (hyperthyroidism may trigger AVNRT or other arrhythmias).
Management
Patients may be instructed to undertake vagal manoeuvres upon the onset of symptoms which can be
effective in stopping the AVNRT. This may involve carotid sinus massage or valsalva manoeuvres, which
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Adenosine, beta-blockers or calcium channel blockers can suppress an AVNRT event by blocking or
slowing the AV node. Other second-line therapies may include amiodarone or flecainide.
Cardioversion is rarely used on patients with AVNRT, usually when the tachycardia is refractory to
other medical therapies or the tachycardia is causing haemodynamic instability (falling blood
pressure, development of heart failure etc.)
Radiofrequency catheter ablation can be offered to patients with frequent attacks for whom medical
therapy isnt appropriate in the long term, and can be curative.
Useful reading
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Filed Under: Cardiology, Clinical Case, ECG, Education, Emergency Medicine, Investigation, Medical Specialty
Tagged With: Atrioventricular Nodal Reentrant Tachycardia, AVNRT, ECG, QRSPT, SVT
Comments
stand says
January 4, 2010 at 1:55 am
Thanks for this post. I really love ECG but could hardly understand AVNRT types; this post
denitely pushed me to read more. Thanks also for the Mayo Clinic link.
Great explanation here too in this book: http://bit.ly/6Cv6Kz
The bottom line is AVNRT is treated the same way regardless of the type (but I still like knowing
the types).
Reply
athikitie says
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Breathe Right nasal strips are designed to help, easy to open nasal passages for interim relief for
stuffy nose. Do you need it? Go to http://www.breatherightnasalstrips.com/
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Eleonard says
October 22, 2010 at 4:14 am
I was diagnose and treated with ablation surgery in 2000 for AVNRT, at the time I was told that
this was passed onto me from another female in my family, and if I were ever to have a female
child I would pass this onto them as well. Can you tell me if this is true? I am now 16 weeks
pregnant and no one seems to know anything about AVNRT
Reply
Zoltan says
February 13, 2012 at 9:16 am
Hi,
Good summary and case. I think though, the 1st tachycardia ECG depicts a typical slow-fast
AVNRT, rather than an atypical fast-slow one; the VA time is very short retrograde Ps just after the
QRS.
Reply
Francis says
August 19, 2012 at 2:14 pm
I agree with Zoltan regarding the rst ECG, should be Slow-fast? An electrophysiologic
examination may need to tell the truth.
Reply
Trackbacks
The ECG Library will leave you feeling ecgstatic! says:
January 10, 2012 at 3:39 pm
[...] AVNRT [...]
Strip 57 StripTease says:
February 14, 2013 at 1:00 pm
[...] are often AV node reentry rhythms where a slow and fast pathway are allowed to form a loop by a PAC
or PVC resetting the fast pathway so that the slow pathway is able to auto-cycle the [...]
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