Supraventricular Supraventricular TachycardiaTachycardiaand Atrial and Atrial

FibrillationFibrillationCourtney Bunevich, D.O.Courtney Bunevich, D.O.

August 15, 2007August 15, 2007

SVT: Clinical FeaturesSVT: Clinical Features

Regular, rapid rhythmRegular, rapid rhythm Usually narrow complex rhythmUsually narrow complex rhythm Arises from atria or atrioventricular nodal Arises from atria or atrioventricular nodal

tissue above the bundle of His that initiate tissue above the bundle of His that initiate and maintain the rhythmand maintain the rhythm

Either a reentry or an ectopic pacemaker Either a reentry or an ectopic pacemaker above the bundle of Hisabove the bundle of His

SVT: PathophysiologySVT: Pathophysiology Reentry: SVT associated with reentry is Reentry: SVT associated with reentry is

PSVTPSVT AV nodal reentry (AVNR) occurs in 60% of casesAV nodal reentry (AVNR) occurs in 60% of cases

Orthodromic AVNR is antrograde conduction via AV Orthodromic AVNR is antrograde conduction via AV node and retrograde conduction via accessory node and retrograde conduction via accessory pathwaypathway

AV reentry via an accessory pathway in 30%AV reentry via an accessory pathway in 30% Intra-atrial reentry s/p cardiac surgery after Intra-atrial reentry s/p cardiac surgery after

large atrial incision with scar formationlarge atrial incision with scar formation Sinus node reentry, inappropriate sinus Sinus node reentry, inappropriate sinus

tachycardia, ectopic junctional tachycardia, and tachycardia, ectopic junctional tachycardia, and nonparoxysmal junctional tachycardia are rarenonparoxysmal junctional tachycardia are rare

PSVT: Clinical FeaturesPSVT: Clinical Features

Can occur in a structurally normal heartCan occur in a structurally normal heart Can be associated with rheumatic heart Can be associated with rheumatic heart

disease, acute pericarditis, MI, MVP, and disease, acute pericarditis, MI, MVP, and preexcitation syndromes.preexcitation syndromes.

Exacerbated by caffeine, alcohol, illicit Exacerbated by caffeine, alcohol, illicit drugs, hyperthyroidism, diet drugs, hyperthyroidism, diet supplements, herbal supplements supplements, herbal supplements (ginseng). Can be induced by PACs and (ginseng). Can be induced by PACs and PVCsPVCs

PSVT: Signs and PSVT: Signs and SymptomsSymptoms

Sudden onset and terminationSudden onset and termination Can occur in patients of all agesCan occur in patients of all ages Regular, tachycardiaRegular, tachycardia Palpitations, anxiety, diaphoresis, Palpitations, anxiety, diaphoresis,

lightheadedness, chest pain, dyspnea, lightheadedness, chest pain, dyspnea, pounding in chest and neck.pounding in chest and neck.

Syncope is uncommonSyncope is uncommon Polyuria if SVT prolonged secondary Polyuria if SVT prolonged secondary

to release of atrial natriuretic peptideto release of atrial natriuretic peptide

Differential DiagnosisDifferential Diagnosis Atrial fibrillation/ Atrial flutter/ MATAtrial fibrillation/ Atrial flutter/ MAT

Onset usually in patients > 60 y/oOnset usually in patients > 60 y/o Patients usually heave heart diseasePatients usually heave heart disease Irregularly Irregular rhythmIrregularly Irregular rhythm

Ventricular TachycardiaVentricular Tachycardia Patients usually > 50 y/oPatients usually > 50 y/o Patients usually have IHDPatients usually have IHD Present with syncope and SCDPresent with syncope and SCD Wide complex regular rhythmWide complex regular rhythm Abrupt onsetAbrupt onset

Physical ExamPhysical Exam

Patient can be diaphoretic, anxious, Patient can be diaphoretic, anxious, hypotensive, or even asymptomatichypotensive, or even asymptomatic

Prominent jugular venous A wave Prominent jugular venous A wave from atrial contraction against from atrial contraction against closed tricuspid valve “frog sign”closed tricuspid valve “frog sign”

Emergency CareEmergency Care

Get immediate set of vital signs including Get immediate set of vital signs including pulse oximetry, IV, O2, monitor.pulse oximetry, IV, O2, monitor.

EKGEKG CKMB and Trop I, TSH, FT4CKMB and Trop I, TSH, FT4 BMPBMP Connect patient to continuous 12 lead Connect patient to continuous 12 lead

EKGEKG Is patient stable? Do they need Is patient stable? Do they need

immediate cardioversion?immediate cardioversion?

EKGEKG

The EKG in PSVT is usually a The EKG in PSVT is usually a narrow, regular complex narrow, regular complex tachycardia.tachycardia.

Less than 10% of cases will have Less than 10% of cases will have SVT with aberrancySVT with aberrancy To be discussed laterTo be discussed later

TreatmentTreatment

Try a vagal maneuver to slow Try a vagal maneuver to slow rhythm to see the underlying rhythm to see the underlying rhythm.rhythm. Carotid sinus massageCarotid sinus massage Do if no bruits auscultated and no Do if no bruits auscultated and no

known carotid diseaseknown carotid disease Massage for 5 seconds and releaseMassage for 5 seconds and release Can also place an ice pack on the Can also place an ice pack on the

foreheadforehead

TreatmentTreatment AdenosineAdenosine

Causes flushing, CP, dyspneaCauses flushing, CP, dyspnea Half life is 15 secondsHalf life is 15 seconds First line treatment is Adenosine 6 mg IVPFirst line treatment is Adenosine 6 mg IVP If unsuccessful, give Adenosine 12mg IVP x 2If unsuccessful, give Adenosine 12mg IVP x 2 Cause transient AV nodal block by hyperpolarization of Cause transient AV nodal block by hyperpolarization of

the nodethe node Complications include bronchospams and VFComplications include bronchospams and VF Will not work if patient has heart transplantWill not work if patient has heart transplant C/I if wide complex tachyarrhythmiaC/I if wide complex tachyarrhythmia Caution in patients with severe COPDCaution in patients with severe COPD Adensione 6mg terminate in 60-80% patientsAdensione 6mg terminate in 60-80% patients Adenosine 12mg will terminate in 90-95% of patientsAdenosine 12mg will terminate in 90-95% of patients

TreatmentTreatment

Next line treatments:Next line treatments: Verapamil 0.075 -0.15 mg /kg IV can Verapamil 0.075 -0.15 mg /kg IV can

repeat in 30 min. Hypotension can repeat in 30 min. Hypotension can occur but can prevent this by giving occur but can prevent this by giving CaCl2 10% 4mL. Not commonly used.CaCl2 10% 4mL. Not commonly used.

Diltiazem 10-20 mg bolus then Diltiazem 10-20 mg bolus then continuous infusion in at 5-15 mg/hourcontinuous infusion in at 5-15 mg/hour

Esmolol protocolEsmolol protocol Metoprolol 5mg IV q5 x 3Metoprolol 5mg IV q5 x 3

TreatmentTreatment

Consider cardioversion or venous atrial or Consider cardioversion or venous atrial or ventricular temporary pacing if unable to ventricular temporary pacing if unable to slow rhythm down with adenosine, CCB, slow rhythm down with adenosine, CCB, and BB before giving antiarrhythmics.and BB before giving antiarrhythmics.

Can also give IV flecainide, IV Can also give IV flecainide, IV procainamide, IV propafenone, IV ibutilideprocainamide, IV propafenone, IV ibutilide

These drugs can cause hypotension, These drugs can cause hypotension, bradycardia, and are proarrhythmic.bradycardia, and are proarrhythmic.

Synchronized Synchronized CardioversionCardioversion

Should be used immediately in any Should be used immediately in any unstable patient with hypotension, unstable patient with hypotension, pulmonary edema, chest pain, or pulmonary edema, chest pain, or other unstable signs.other unstable signs.

Required dose is usually small: 50 Required dose is usually small: 50 JoulesJoules

Long term TreatmentLong term Treatment

Risk of developing long term PSVT Risk of developing long term PSVT after single episode not defined. One after single episode not defined. One episode is not indication for long episode is not indication for long term treatment.term treatment.

Long term TreatmentLong term Treatment

SVT with No PreexcitationSVT with No Preexcitation Verapamil, Beta blockers, and DiltiazemVerapamil, Beta blockers, and Diltiazem Decrease symptoms in 30-60%Decrease symptoms in 30-60% Randomized clinical trials show no Randomized clinical trials show no

superioritysuperiority Failure on a single drug therapy can try a Failure on a single drug therapy can try a

combo of two or add one a class IC or class combo of two or add one a class IC or class III antiarrhythmicIII antiarrhythmic

Long term treatment with class IC not Long term treatment with class IC not recommended, and patents should be recommended, and patents should be referred for catheter ablationreferred for catheter ablation

Catheter AblationCatheter Ablation Radiofrequency and CyrothermalRadiofrequency and Cyrothermal 95% success rate initially95% success rate initially <5% recurrence rate in the 1<5% recurrence rate in the 1stst few months few months Complications occur in 2-3%Complications occur in 2-3%

Damage to arteries, bleeding, AVF, venous Damage to arteries, bleeding, AVF, venous thrombosis, PE, myocardial perforation, thrombosis, PE, myocardial perforation, valvular damage, systemic embolism, and valvular damage, systemic embolism, and death (rare)death (rare)

Blocking near the AV node can cause total Blocking near the AV node can cause total block of the AV node and patient will need a block of the AV node and patient will need a pacemakerpacemaker

Wolf Parkinson WhiteWolf Parkinson White

Associated Ebstein’s anomalyAssociated Ebstein’s anomaly EKG will show a short PR interval, a EKG will show a short PR interval, a

delta wave, and a QRS interval up to delta wave, and a QRS interval up to 0.12 msec0.12 msec

Accessory pathway is the Bundle of Accessory pathway is the Bundle of KentKent

Wolf Parkinson WhiteWolf Parkinson White

Has 2 mechanisms for PSVTHas 2 mechanisms for PSVT Orthodromic, narrow complex (95%)Orthodromic, narrow complex (95%)

Antrograde conduction via AV node and Antrograde conduction via AV node and retrograde conduction via accessory pathwayretrograde conduction via accessory pathway

Can treat like PSVTCan treat like PSVT Antidromic, wide complex (5%)Antidromic, wide complex (5%)

Antrograde conduction via accessory pathway Antrograde conduction via accessory pathway and retrograde conduction via AV nodeand retrograde conduction via AV node

DO NOT give Digoxin, BB, VerapamilDO NOT give Digoxin, BB, Verapamil Try procainamide and cardioversionTry procainamide and cardioversion

SVT with WPWSVT with WPW

Catheter ablation is the treatment of Catheter ablation is the treatment of choice once stablechoice once stable

Risk of sudden death is 0.15 – 0.45 Risk of sudden death is 0.15 – 0.45 % / year% / year

Wolf Parkinson WhiteWolf Parkinson White

Can degenerate into Atrial FibrillationCan degenerate into Atrial Fibrillation If life threatening: do immediate If life threatening: do immediate

cardioversion.cardioversion.

If not unstable, you can try If not unstable, you can try procainamine, amiodarone, or lidocaineprocainamine, amiodarone, or lidocaine

Caution verapamil, BB, and digoxin will Caution verapamil, BB, and digoxin will cause degeneration into ventricular cause degeneration into ventricular fibrillation!!fibrillation!!

SVT with aberrancySVT with aberrancy

Occur in less than 10% of casesOccur in less than 10% of cases Regular, wide complex tachycardiaRegular, wide complex tachycardia Causes:Causes:

SVT with a preexcitation syndromeSVT with a preexcitation syndrome Antidromic reentry seen in <5% cases of Antidromic reentry seen in <5% cases of

patients who have WPWpatients who have WPW Patient with a preexisting BBBPatient with a preexisting BBB Bundle branch fatigue in PSVTBundle branch fatigue in PSVT

Atrial FibrillationAtrial Fibrillation

Uncoordinated atrial activation with Uncoordinated atrial activation with deterioration of atrial mechanical deterioration of atrial mechanical dysfunctiondysfunction

Ventricular response to atrial Ventricular response to atrial fibrillation depends on the integrity fibrillation depends on the integrity and electrophysical properties of the and electrophysical properties of the AV nodeAV node

Most common arrhythmia Most common arrhythmia encountered in clinical practiceencountered in clinical practice

Atrial FibrillationAtrial Fibrillation Most common sustained tachyarrhythmia Most common sustained tachyarrhythmia

patients seek treatment forpatients seek treatment for Affects 0.4-1% of the general population and Affects 0.4-1% of the general population and

8% of patients greater than 80 years old8% of patients greater than 80 years old AF occurring in patient without structural AF occurring in patient without structural

heat disease and less than 65 y/o is termed heat disease and less than 65 y/o is termed lone AFlone AF

Types:Types: First episodeFirst episode Paroxysmal (self-terminating)Paroxysmal (self-terminating) Persistent (requiring electrical or pharmacological Persistent (requiring electrical or pharmacological

treatment)treatment) PermanentPermanent

Atrial FibrillationAtrial Fibrillation Irregularly, irregular rhythmIrregularly, irregular rhythm Can be associated with rapid ventricular Can be associated with rapid ventricular

conduction/response or AF with RVRconduction/response or AF with RVR No atrial kick in atrial fibrillation. The firing of the No atrial kick in atrial fibrillation. The firing of the

atria and ventricles is not synchronized. In patients atria and ventricles is not synchronized. In patients with systolic dysfunction, the atria makes an with systolic dysfunction, the atria makes an important contributionimportant contribution

Biopsies have shown patchy fibrosis of fibers in atriaBiopsies have shown patchy fibrosis of fibers in atria Foci can be found in atria, pulmonary arteries, Foci can be found in atria, pulmonary arteries,

coronary sinuscoronary sinus Atrial rate is 350-600 beats/minAtrial rate is 350-600 beats/min Multiple small areas of the atria are firing and Multiple small areas of the atria are firing and

contracting (quivering)contracting (quivering) Ventricular conduction rate is variable 40-180 bpmVentricular conduction rate is variable 40-180 bpm

Causes for Atrial Causes for Atrial FibrillationFibrillation

Rheumatic heart diseaseRheumatic heart disease Nonrheumatic mitral valve disease diseaseNonrheumatic mitral valve disease disease HypertensionHypertension Chronic lung diseaseChronic lung disease ASDASD Thyrotoxicosis *Thyrotoxicosis * Lone AFLone AF Ischemic heart disease Ischemic heart disease Acute MI *Acute MI * Dilated cardiomyopathyDilated cardiomyopathy Holiday heart- Alcohol ingestion *Holiday heart- Alcohol ingestion * Theophylline toxicityTheophylline toxicity PheochromocytomaPheochromocytoma

Causes for Atrial Causes for Atrial FibrillationFibrillation

Pericarditis *Pericarditis * Electrocution *Electrocution * Post cardiothoracic surgery *Post cardiothoracic surgery * Myocarditis *Myocarditis * Pulmonary embolism *Pulmonary embolism * ObesityObesity Intracardiac tumors or thrombiIntracardiac tumors or thrombi AmyloidosisAmyloidosis SAH or CVASAH or CVA Familial AFFamilial AF

Signs and SymptomsSigns and Symptoms

Can be severe:Can be severe: Pulmonary edema, palpitations, angina, Pulmonary edema, palpitations, angina,

and syncopeand syncope Relatively asymptomaticRelatively asymptomatic Nonspecific symptoms such as fatigueNonspecific symptoms such as fatigue

Treatment of AF with Treatment of AF with RVRRVR

Get an immediate set of vitals, pulse Get an immediate set of vitals, pulse oximetry. Place a patient on a monitor and oximetry. Place a patient on a monitor and O2. Get IV access. O2. Get IV access.

Get EKG. Check BMP.Get EKG. Check BMP. Check CKMB and Trop I. Get CXR.Check CKMB and Trop I. Get CXR. Check TSH and FT4.Check TSH and FT4. How long has AF been present? <48hrs or How long has AF been present? <48hrs or

>48hrs or unknown>48hrs or unknown Is patient unstable? Do they need Is patient unstable? Do they need

immediate cardioversion?immediate cardioversion?

Treatment of AF with RVRTreatment of AF with RVRRate ControlRate Control

Medications: IF preserved EF > 40%Medications: IF preserved EF > 40% Diltiazem 10-20 mg IV bolus and run a Diltiazem 10-20 mg IV bolus and run a

drip in at 5-15 mg/hour. Can repeat the drip in at 5-15 mg/hour. Can repeat the bolus if needed.bolus if needed.

Esmolol protocolEsmolol protocol Metoprolol 5mg IV q5 min x 3Metoprolol 5mg IV q5 min x 3

Treatment of AF with RVRTreatment of AF with RVRRate ControlRate Control

Medications: If EF < 40%Medications: If EF < 40% Recommend:Recommend: Diltiazem 10-20 mg IV bolus and run a Diltiazem 10-20 mg IV bolus and run a

drip in at 5-15 mg/hour. Can repeat the drip in at 5-15 mg/hour. Can repeat the bolus if needed.bolus if needed.

Amiodarone 150mg IV over 1 minute Amiodarone 150mg IV over 1 minute then 1 mg/minute for 6 hours then 0.5 then 1 mg/minute for 6 hours then 0.5 mg/min for 18 hoursmg/min for 18 hours Caution if patient on digoxinCaution if patient on digoxin Watch for hypotensionWatch for hypotension Low efficacy for acute conversionLow efficacy for acute conversion

Treatment of AF with RVRTreatment of AF with RVRRhythm ControlRhythm Control

If duration is < 48 hours and EF > If duration is < 48 hours and EF > 40%40%

DC Cardioversion at 100 Joules DC Cardioversion at 100 Joules (60%) , 200 Joules (80%)(60%) , 200 Joules (80%)

ONLY ONE of the following: ONLY ONE of the following: Amiodarone, ibutilide, flecainide, Amiodarone, ibutilide, flecainide, propafenone, and procainamidepropafenone, and procainamide

Treatment of AF with RVRTreatment of AF with RVRRhythm ControlRhythm Control

If duration < 48 hours and EF< 40%If duration < 48 hours and EF< 40%

DC cardioversion or AmiodaroneDC cardioversion or Amiodarone

Treatment of AF with RVRTreatment of AF with RVRRhythm ControlRhythm Control

If duration > 48 hours or unknownIf duration > 48 hours or unknown

Do rate control. Start anticoagulation for Do rate control. Start anticoagulation for 4 weeks with therapeutic INR. Exclude 4 weeks with therapeutic INR. Exclude clot. Do cardioversion. Continue clot. Do cardioversion. Continue anticoagulation for 4 more weeks.anticoagulation for 4 more weeks.

Begin IV heparin. TEE exclude clot. Begin IV heparin. TEE exclude clot. Cardioversion. Anticoagulation for 4 Cardioversion. Anticoagulation for 4 weeks.weeks.

TEETEE TEE will show thrombus in 5-15% in atrial TEE will show thrombus in 5-15% in atrial

fibrillation preparing for cardioversionfibrillation preparing for cardioversion Thromboembolic events have been Thromboembolic events have been

reported after “normal” TEE and reported after “normal” TEE and cardioversioncardioversion

Contrast enhanced MRI is evolving Contrast enhanced MRI is evolving diagnostic modality for evaluation diagnostic modality for evaluation intracardiac thrombiintracardiac thrombi

Statins have been shown to decreases risk Statins have been shown to decreases risk of recurrent AF after cardioversion of recurrent AF after cardioversion possible due to anti-inflammatory affectspossible due to anti-inflammatory affects

Atrial FibrillationAtrial Fibrillation

AFFIRM trial 2002 showed no AFFIRM trial 2002 showed no mortality differences between rate mortality differences between rate and rhythm control groups. Rhythm and rhythm control groups. Rhythm control should be reserved for control should be reserved for patients who are symptomatic even patients who are symptomatic even when rate controlled.when rate controlled.

Patients need either rate or rhythm Patients need either rate or rhythm control and anticoagulationcontrol and anticoagulation

New Onset AFNew Onset AF

Minimal Evaluation:Minimal Evaluation: H and P for symptoms, type of AF, date H and P for symptoms, type of AF, date

of onset and duration, treatment given, of onset and duration, treatment given, co-morbid or predisposing conditionsco-morbid or predisposing conditions

ECG- evaluate rhythm, LVH, ECG- evaluate rhythm, LVH, preexcitation syndromes, BBB, and old preexcitation syndromes, BBB, and old MIMI

TTE- evaluate LV function, clots TTE- evaluate LV function, clots (inferior), valvular disease(inferior), valvular disease

Labs: TSH, Renal and Hepatic functionLabs: TSH, Renal and Hepatic function

New Onset AFNew Onset AF

Additional Testing:Additional Testing: 6 minute walk test to assess for 6 minute walk test to assess for

adequate rate controladequate rate control Exercise stress testExercise stress test Holter monitorHolter monitor TEETEE Electrophysical studiesElectrophysical studies

Atrial FibrillationAtrial Fibrillation AFFIRM trial showed that patients despite AFFIRM trial showed that patients despite

being in sinus rhythm are still at high risk of being in sinus rhythm are still at high risk of stroke.stroke.

Patients with paroxsymal AF still must be Patients with paroxsymal AF still must be anticoagulated.anticoagulated.

CHADS2: criteria recommended that scores 0-CHADS2: criteria recommended that scores 0-2 can use aspirin safely and scores greater 2 can use aspirin safely and scores greater than 3 need warfarin in those with nonvalvular than 3 need warfarin in those with nonvalvular AF AF CHF – 1 pointCHF – 1 point HTN – 1 pointHTN – 1 point Age > 75 years – 1 pointAge > 75 years – 1 point DM – 1 pointDM – 1 point Prior Stroke or TIA – 2 pointsPrior Stroke or TIA – 2 points

CHADS2CHADS2

Score:Score: 00 11 22 33 44 55 66

Stroke rate per Stroke rate per year (%):year (%): 1.91.9 2.82.8 4.04.0 5.95.9 8.58.5 12.512.5 18.218.2

Risk of StrokeRisk of Stroke

Atrial fibrillation is associated with increased Atrial fibrillation is associated with increased risk of stroke, heart failure, and all cause risk of stroke, heart failure, and all cause mortalitymortality

5% per year risk of CVA in patients with 5% per year risk of CVA in patients with nonvalvular atrial fibrillationnonvalvular atrial fibrillation

Framingham study showed 17 times increased Framingham study showed 17 times increased risk of CVA in patients with valvular AF and 5 risk of CVA in patients with valvular AF and 5 times increased risk in those with nonvalvular times increased risk in those with nonvalvular AFAF

1.5% risk of CVA in patients age 50-591.5% risk of CVA in patients age 50-59 23.5% risk of CVA in patients age 80-8923.5% risk of CVA in patients age 80-89

Risk of StokeRisk of Stoke

NYHA NYHA classification:classification:

II

II-IIIII-III

IVIV

Risk of stroke/year Risk of stroke/year (%):(%):

4%4%

12-26%12-26%

27-50%27-50%

Risk of StrokeRisk of Stroke

Risk Factors:Risk Factors:

CVA/TIACVA/TIA DMDM HTNHTN HFHF Age per decadeAge per decade

Relative Increased Relative Increased Risk:Risk:

2.52.5 1.71.7 1.61.6 1.41.4 1.41.4

ASA TreatmentASA Treatment

Treat of AF with ASA is a Class I Treat of AF with ASA is a Class I recommendation by the 2006 ACC recommendation by the 2006 ACC guidelines in the following subsets of guidelines in the following subsets of patients:patients: Age < 60 and no heart diseaseAge < 60 and no heart disease Age 60-74 with heart disease and no Age 60-74 with heart disease and no

risk factorsrisk factors Age 60-74 and no heart diseaseAge 60-74 and no heart disease

Risk factors: Heart failure, EF<35%, HTNRisk factors: Heart failure, EF<35%, HTN

Pharmacologic Pharmacologic CardioversionCardioversion

Ibutilide is the only drug FDA approved Ibutilide is the only drug FDA approved for pharmacologic cardioversionfor pharmacologic cardioversion

45% conversion rate for AF45% conversion rate for AF 60% conversion rate for Atrial Flutter60% conversion rate for Atrial Flutter Class III agent with a 4-8% risk of TdPClass III agent with a 4-8% risk of TdP

Higher if patient has CHF or cardiomyopathyHigher if patient has CHF or cardiomyopathy 0.01mg/kg (max 1 mg) over 10 minutes0.01mg/kg (max 1 mg) over 10 minutes Have external defibrillator readyHave external defibrillator ready Monitor of telemetry for at least 4 hoursMonitor of telemetry for at least 4 hours

Pharmacologic Pharmacologic CardioversionCardioversion

Digoxin and sotalol are NOT recommended Digoxin and sotalol are NOT recommended for pharmacologic cardioversionfor pharmacologic cardioversion

These drugs gave Class I and IIa These drugs gave Class I and IIa recommendations for pharmacologic recommendations for pharmacologic cardioversion:cardioversion: DofetildeDofetilde FlecanideFlecanide PropafenonePropafenone IbutilideIbutilide Amiodarone (IIa)Amiodarone (IIa)

Electrical CardioversionElectrical Cardioversion

Recommended if symptoms are known Recommended if symptoms are known to be less than 48 hoursto be less than 48 hours

Unstable in patients without accessory Unstable in patients without accessory pathwaypathway

Unstable or in tachycardic patients with Unstable or in tachycardic patients with an accessory pathwayan accessory pathway

Patients unable to tolerate symptoms Patients unable to tolerate symptoms Contraindicated in hypokalemia and Contraindicated in hypokalemia and

digitalis toxicitydigitalis toxicity

Other TreatmentsOther Treatments

Maze procedureMaze procedure Can do as an adjunct procedure during Can do as an adjunct procedure during

open heart surgeriesopen heart surgeries Catheter ablation after EP studies to Catheter ablation after EP studies to

determine irritable focidetermine irritable foci AVN ablation can be useful in patients with AVN ablation can be useful in patients with

tachycardia-mediated cardiomyopathytachycardia-mediated cardiomyopathy Small study showed increase in EF from Small study showed increase in EF from

26% to 34% after AVN and pacemaker 26% to 34% after AVN and pacemaker implantationimplantation

ReferencesReferences Harrison’s Internal Medicine 16Harrison’s Internal Medicine 16thth Edition Edition 2006 ACC Guideline for Atrial Fibrillation2006 ACC Guideline for Atrial Fibrillation New England Journal of MedicineNew England Journal of Medicine

Supraventicular TachycardiaSupraventicular Tachycardia 9 March 2006 pp 1039 volume 3549 March 2006 pp 1039 volume 354

American Journal of Emergency MedicineAmerican Journal of Emergency Medicine Wide Complex Tachycardias: Beyond Traditional Wide Complex Tachycardias: Beyond Traditional

Differential Diagnosis of Ventricular Tachycardia versus Differential Diagnosis of Ventricular Tachycardia versus SVT with Aberrant Conduction SVT with Aberrant Conduction

November 2005 pp 876 volume 23November 2005 pp 876 volume 23 New England Journal of MedicineNew England Journal of Medicine

AFFRIM Trial pp 1825 volume 347AFFRIM Trial pp 1825 volume 347