Tachyarrhythmia

SVT
VT
Prof. Beishenkulov MT
Normal ECG
Possible responses of narrow QRS tachycardia
to vagal manoeuvres and adenosine
(1) Slowing of AVN conduction and induction of intermittent AV block.
Atrial electrical activity can thus be unmasked, revealing dissociated P waves (focal AT,
atrial flutter, or AF waves).
(2) Temporary decrease in the atrial rate of automatic tachycardias (focal AT, sinus
tachycardia, and JET).
(3) Tachycardia termination. This can happen by interrupting the re-entry circuit in AVNRT
and AVRT by acting on the AVN that is part of the circuit. More rarely, sinus nodal re-entry
and ATs due to triggered activity can slow down and terminate.
(4) No effect is observed in some cases.
Haemodynamic instability
• Arterial hypotension (BPsyst < 90 mm Hg)
• Decompensated heart failure
• Ischemia on ECG
• Syncope
Causes of sinus tachycardia
• Physiological causes: Emotion, physical exercise, sexual intercourse, pain,
pregnancy
• Pathological causes: Anxiety, panic attack, anaemia, fever, dehydration,
infection, malignancies, hyperthyroidism, hypoglycaemia, pheochromocytoma,
Cushing’s disease, diabetes mellitus with evidence of autonomic dysfunction,
pulmonary embolus, myocardial infarction, pericarditis, valve disease,
congestive heart failure, shock
• Drugs: Epinephrine, norepinephrine, dopamine, dobutamine, atropine, beta-2
adrenergic receptor agonists (salbutamol), methylxanthines, doxorubicin,
daunorubicin, beta-blocker withdrawal
• Illicit drugs: Amphetamines, cocaine, lysergic acid diethylamide, psilocybin,
ecstasy, crack, cocaine
• Other: Caffeine, alcohol
Focal atrial tachycardia
AV nodal tachycardia
AVRT
VT
VT
Management of Sustained Monomorphic VT
Sustained
Monomorphic VT
Direct current
Hemodynamic
Stable Unstable cardioversion &
stablility
ACLS
12-lead ECG,
history & physical
Consider disease Cardioversion

specific VTs (Class I)
Structural IV procainamide VT
Yes
heart disease (Class IIa) termination
No IV amiodarone or
sotalol Yes No
(Class IIb)
Typical ECG
morphology for Therapy guided
by underlying Cardioversion
idiopathic VA
heart disease (Class I)
Verapamil sensitive VT* : verapamil VT

or Yes
termination
Outflow tract VT: beta blocker
for acute termination of VT
Yes
(Class IIa) No
Sedation/anesthesia,
Cardioversion VT reassess antiarrhythmic
Effective No termination therapeutic options,
(Class I)
repeat cardioversion
Yes No
Therapy to prevent Catheter ablation

recurrence preferred (Class I)
Verapamil or
Catheter ablation beta blocker
(Class I) (Class IIa)
Colors correspond to Class of Recommendation in Table 1.

*Known history of Verapamil sensitive or classical ECG presentation.
ACLS indicates advanced cardiovascular life support; ECG, electrocardiogram; VA,
ventricular arrhythmia; and VT, ventricular tachycardia.
Secondary and Primary Prevention of SCD in
Patients With NICM
Patients with NICM
SCA survivor/ NICM due to

Symptoms Class II-III
sustained VT LMNA mutation
No concerning No HF and No
(spontaneous/ and 2º risk
for VA LVEF ≤35%
inducible) factors
Yes Yes
Yes
Yes
Arrythmogenic ICD ICD

ICD candidate* candidate*
syncope
candidate*
suspected
Yes No, due to newly Yes

Yes No Yes Etiology uncertain diagnosed HF
(<3 mo GDMT)
ICD Amiodarone ICD EP Study ICD or not on optimal ICD
(Class I) (Class IIb) (Class IIa) (Class IIa) (Class I) GDMT (Class IIa)
If positive
If LVEF ≤35%
and WCD
Class II-III (Class IIb)
HF
Reassess
LVEF ≥3mo

*ICD candidacy as determined by functional status, life expectancy or patient
preference.
2° indicates secondary; EP, electrophysiological; GDMT, guideline-directed
management and therapy; HF, heart failure; ICD, implantable cardioverter-
defibrillator; LVEF, left ventricular ejection fraction; NICM, nonischemic
cardiomyopathy; SCA, sudden cardiac arrest; SCD, sudden cardiac death; VA,
ventricular arrhythmia; and WCD, wearable cardiac-defibrillator.
Prevention of SCD in Patients With Long QT
Syndrome
LQTS QT prolonging drugs/
hypokalemia/
Resuscitated hypomagnesemia
cardiac arrest (Class III: Harm)
QTc <470 ms QTc ≥470 ms and/
or symptomatic
ICD Beta blocker
candidate* (Class I)
Beta blocker Beta blocker
(Class IIa) (Class I)
ICD
(Class I)
Persistent symptoms
Recurrent ICD Asymptomatic and
and/or other high-risk
shocks for VT QTc >500 ms
features†
Treatment intensification: Treatment intensification: Treatment intensification:

additional medications, additional medications, additional medications,
left cardiac sympathetic left cardiac sympathetic left cardiac sympathetic
denervation denervation and/or an ICD denervation and/or an ICD
(Class I) (Class I) (Class IIb)

*ICD candidacy as determined by functional status, life expectancy, or patient
preference.
†High-risk patients with LQTS include those with QTc >500 ms, genotypes LQT2 and
LQT3, females with genotype LQT2, <40 years of age, onset of symptoms at <10
years of age, and patients with recurrent syncope
ICD indicates implantable cardioverter-defibrillator; LQTS, long-QT syndrome; VT,
ventricular tachycardia.

Tachyarrhythmia

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Tachyarrhythmia

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SVT

Consider disease Cardioversion

Verapamil sensitive VT* : verapamil VT

Therapy to prevent Catheter ablation

Colors correspond to Class of Recommendation in Table 1.

SCA survivor/ NICM due to

Arrythmogenic ICD ICD

Yes No, due to newly Yes

Colors correspond to Class of Recommendation in Table 1.

Treatment intensification: Treatment intensification: Treatment intensification:

Colors correspond to Class of Recommendation in Table 1.

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