A practical approach to clinical arrhythmology by Josep Brugada & Lluís Mont

Author:Josep Brugada & Lluís Mont [Brugada , Josep]
Language: eng
Format: azw3, mobi, pdf
Publisher: Marge Books
Published: 2016-12-19T16:00:00+00:00

Chapter 10. Atrioventricular nodal tachycardia: a simple and fast approach to cure

P. BRUGADA,1 S.A. MÜLLER-BURRI,2 J. BRUGADA3 1 Cardiovascular Division

UZ Brussel-VUB

Brussels, Belgium

2 Heart Rhythm Management Centre UZ Brussel-VUB

Brussels, Belgium

3 Hospital Clínic, Fundació Clínic University of Barcelona

Barcelona, Spain

Address for correspondence: Hospital Clínic Fundació Clínic, University of Barcelona Dr. Pedro Brugada [email protected]

Introduction Atrioventricular nodal tachycardia (AVNT) is one of the most common cardiac arrhythmias.1,2 AVNT is almost never life threatening with some exceptions: patients developing syncope because of very fast AVNT and patients with structural heart disease. However, AVNT can have a very negative impact on the quality of life of the patient. Not only because of the complaints, need of antiarrhythmic drug treatment or admission to the emergency room to terminate the arrhythmia, but also because AVNT is the most undiagnosed rhythm disturbance: AVNT occurs most commonly in young women in whom doctors underestimate the significance of paroxysmal palpitations unless an electrocardiogram (ECG) has documented the arrhythmia. Many patients with AVNT never reach the physician or the emergency room in time to have an ECG recorded during the complaints. The result can be very disastrous: the physician considers the complaints of palpitations as “functional”, related to hyperventilation or anxiety disorders and the patient is irremediably placed on anti-depressive drugs. Of course these drugs have no effect at all to prevent new episodes of AVNT and a negative vicious circle between patient-doctor-medication-complaints is created that can even end with the admission of the patient into a psychiatric institution. That this is the reality is shown by the data that we collected many years ago on the diagnosis made by general practitioners in patients with proven supraventricular tachycardia. Depending upon the moment when the doctor saw the patient (during or outside the episode of arrhythmia) the diagnosis was very different (see table 1). Patients seen outside the episode of tachycardia were invariably diagnosed as suffering from hyperventilation, anxiety, sinus tachycardia or “stress”. On the contrary, when the patients were seen during the arrhythmia, a diagnosis of tachycardia was suspected in the majority. Most supraventricular tachycardias are at the present time perfectly curable with catheter ablation obviating the need for unnecessary suffering and life-long antiarrhythmic drug treatment. To

Diagnosis During tachycardia Outside tachycardia

Arrhythmia 43 (93 %) 12 (7 %)

Hyperventilation 2 36

Sinus tachycardia 1 28

Anxiety 0 23

No abnormalites 0 78

Total 46 177

Table 1. Missing the diagnosis of tachycardia (223 patients seen by the general practitioner).

cure patients with AVNT, however, a perfectly integrated approach to diagnosis, referral and treatment is required.

In this article we describe the five clinical pathways for the rapid and effective diagnosis and cure of patients suffering from AVNT.

1 Thinking about AVNT: the “frog” sign AVNT is a quite particular arrhythmia. It originates in the AV node and its anatomic basis is the presence of at least two (sometimes multiple) AV nodal pathways (see figure 1). Whether these dual or multiple AV nodal pathways are located within the AV node or are mere prolongations of the AV node with part of the atrium involved in the arrhythmia is still a matter of heavy electrophysiological discussion.

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