• Clinical science
  • Physician

Management of tachycardia

Summary

Tachycardia is defined as a heart rate that exceeds 100/minute. Signs of unstable tachycardia include chest pain, shock, and impaired consciousness. Unstable tachycardia is considered an emergency and should be managed with immediate electrical cardioversion. In stable tachycardias, both the cardiac rhythm (i.e., regular or irregular) and the QRS complex (i.e., narrow-complex tachycardia and wide-complex tachycardias) should be evaluated. Undifferentiated regular supraventricular tachycardia (SVTs) should be initially managed with a trial of vagal maneuvers and, if necessary, IV adenosine. Irregular SVTs are usually caused by atrial fibrillation (Afib) or atrial flutter, which are managed either with a rate control strategy (e.g., with β-blockers or calcium channel blockers) or a rhythm control strategy (i.e., with antiarrhythmics or electrical cardioversion) in combination with risk-based anticoagulation therapy. Undifferentiated wide-complex tachycardias (WCTs) should be managed with electrical cardioversion or pharmacological cardioversion. If a stable patient becomes unstable at any point during management, immediate electrical cardioversion is recommended regardless of the rhythm. The content in this article is organized to first provide management steps for undifferentiated arrhythmias but also includes management for specific rhythms, once identified. Unstable tachycardia without a pulse, ventricular fibrillation, and cardiac arrest are not addressed here (see ACLS).

Approach

1. ABCDE survey [1]

  • No pulse: Start CPR (see ACLS).
  • Pulse present: Continue stepwise approach through ABCDE and proceed to the next step.
    • Continuous telemetry
    • Continuous pulse oximetry
    • Crash cart at the bedside
    • Frequent blood pressure assessment
    • Supplemental oxygen as needed
    • Obtain IV access.
    • Identify and treat reversible causes

2. Determine if the patient is stable or unstable

Examine patients for unstable signs of tachycardia so that immediate electrical cardioversion can be initiated if indicated.

3. Obtain a 12-lead ECG

  1. Evaluate whether it is a wide-complex tachycardia (WCT) or narrow-complex tachycardia (NCT).
  2. Determine whether the rhythm is regular or irregular (e.g., RR intervals regular or irregular).
  3. Review previous ECGs if available to look for pre-existing abnormalities that may affect treatment choices, e.g.:

4. Identify and treat the cardiac rhythm according to acute management algorithm

Differential diagnosis of tachycardia based on ECG findings
Rhythm Narrow-complex QRS Wide-complex QRS
Regular
Irregular

Unstable tachycardia with pulse

For unstable tachycardia without a pulse, start CPR (see ACLS).

Signs of unstable tachycardia [1]

Initial management

  • Obtain a crash cart, defibrillator device, suction, bag-mask device, and airway and intubation equipment.
  • Call for help (e.g., urgent cardiology consult and/or anesthesia consult)
  • Administer supplemental oxygen, if needed.
  • If unstable signs of tachycardia are present and instability is likely due to tachycardia, perform immediate electrical cardioversion.
    • HR > 150/min: Unstable signs are likely due to tachycardia.
    • HR 100–150/min: Suspect another underlying condition.

Electrical cardioversion [1][4]

  • Synchronized electrical cardioversion is indicated in almost all unstable patients with tachycardia and a pulse. [1]
  • Defibrillation is only indicated if either of the following is the case: [5]
    • An irregular wide-complex cardiac rhythm is identified.
    • The device fails to synchronize with the patient's cardiac rhythm.

Ensure oxygen is turned off or that the flow of oxygen is moved away from the patient during cardioversion, as oxygen is a flammable gas!

Procedural sedation

Do not delay cardioversion for the sake of sedation!

Synchronized electrical cardioversion [4][1][5]

Indications

  • Unstable narrow-complex tachycardia with pulse
  • Unstable regular wide-complex tachycardia with pulse

Steps

  • Preparation and procedural sedation
  • Place paddles or electrode pads firmly on the thorax of the patient (anteroapical or anteroposterior position).
  • Choose the synchronized (SYNC) mode of shock on the defibrillator device.
  • Select the recommended dose of electrical energy according to the patient's cardiac rhythm. [5][1][4]
    • Regular narrow-complex tachycardia: 50–100 J biphasic waveform
    • Irregular narrow-complex tachycardia: 120–200 J biphasic waveform (preferred) OR 200 J monophasic [8]
    • Regular wide-complex tachycardia: 100 J biphasic waveform
  • “Clear” the patient.
  • Deliver shock.
  • Reassess the rhythm and check the pulse.

Defibrillation [9]

Indications

  • Unstable irregular wide-complex tachycardia with pulse
  • Pulseless patient/cardiac arrest (see ACLS)

Steps

  • Preparation and procedural sedation for cardioversion
  • Place paddles or electrode pads firmly on the thorax of the patient (anteroapical or anteroposterior position).
  • Choose the unsynchronized mode of shock on the defibrillator device.
  • Select the defibrillator dose: 120–200 J biphasic waveform. [1]
  • “Clear” the patient.
  • Deliver shock.
  • Reassess the rhythm and check the pulse.

Subsequent management

  • Reversion to sinus rhythm (i.e., successful cardioversion)
    • Urgent cardiology consult
    • Consider anticoagulation.
    • Transfer to ICU or CCU.
    • Continuous telemetry and pulse oximetry
  • Persistent arrhythmia (i.e., failure to cardiovert)
    • Administer a second dose of cardioversion
    • Call for expert help.
    • Consider antiarrhythmic infusion in consultation with a cardiologist.
    • Continue resuscitation.
  • Deterioration to a life-threatening rhythm or pulseless patient: Start CPR (see ACLS).

Stable, regular narrow-complex tachycardia

Approach to management [10]

  1. Determine the underlying rhythm.
  2. Consult cardiology for definitive management and follow-up.

Management of undifferentiated SVT [11][10]

  1. Perform vagal maneuvers. [11]
  2. Reassess the rhythm.
    • Rhythm reverts to normal sinus rhythm: Monitor for recurrence.
    • Regular SVT is identified:
      • No contraindications to adenosine: Administer adenosine.
      • Contraindications to adenosine present: Administer an AV-nodal blocking agent (see below).
    • Irregular SVT is identified: See management of stable, irregular narrow-complex tachycardia.
  3. If regular or undifferentiated SVT persists despite adenosine, administer one of the following:
  4. If regular or undifferentiated SVT persists despite the above measures:
  5. Consult cardiology for definitive management.

If the patient becomes hemodynamically unstable, perform synchronized electrical cardioversion.

Calcium channel blockers should be avoided if there is any concern for ventricular tachycardia, as they can precipitate ventricular fibrillation.

Differential diagnosis of SVT

Rhythm Typical ECG findings [12][10][13] Acute management
Sinus tachycardia [14][10][15]
  • Regular sinus P wave
  • Ventricular rhythm: regular
  • Atrial rate = ventricular rate
  • HR rarely exceeds 150–180/min [13]
  • Identify and treat the underlying cause.
  • Physiological sinus tachycardia: No specific treatment required.
  • Inappropriate sinus tachycardia (IST): cardiology consult to rule out other conditions that closely mimic IST and treat accordingly
Atrioventricular nodal re-entrant tachycardia (AVNRT)
  • P wave rarely detectable
  • Infrequent finding: abnormal P wave before or after a QRS complex
  • Ventricular rhythm (RR interval): regular
  • Pseudo-R wave in V1 and/or a pseudo-S wave in inferior lead
  • HR: 110–250/min

Orthodromic AVRT

  • P wave rarely detectable
  • Ventricular rhythm (RR interval): regular
  • RP interval shorter than PR interval (RP < 70 ms)
  • HR: 120–240/min

Focal atrial tachycardia

  • P wave may be detectable but may be obscured by the T wave of the previous QRS complex.
  • P wave morphology can be abnormal.
  • Ventricular rhythm (RR interval): regular
  • RP interval longer than PR interval (RP > 70 ms)
  • Atrial rate > ventricular rate
  • HR: usually between 100–250/min
Atrial flutter with fixed AV conduction
  • Flutter waves (sawtooth appearance)
  • Ventricular rhythm (RR interval): regular
  • Atrial rate > ventricular rate
  • HR: 75–150/min (depending on conduction)

If it is not possible to differentiate between the different types of SVT and expert consultation is not available, treat tachycardia as undifferentiated SVT.

Stable, irregular narrow-complex tachycardia

Approach to management [1]

  1. Determine the underlying rhythm.
  2. Consult cardiology for definitive management and follow-up.

Differential diagnosis of irregular, narrow-complex tachycardia

Rhythm

Typical ECG findings Acute management
Atrial fibrillation with rapid ventricular response
(Afib with RVR)
[10][16][17]
  • Fibrillatory waves
  • Rhythm: irregularly irregular
  • PR intervals: not distinguishable
  • Absent isoelectric baseline
  • Atrial rate > ventricular rate
  • HR is variable; in Afib with RVR: 100–180/min
Atrial flutter with variable conduction [10][16][17]
  • Flutter waves (sawtooth appearance)
  • Rhythm: irregularly irregular
  • PR intervals: not distinguishable
  • Atrial rate > ventricular rate
  • HR is variable; typically 100–180/min
Multifocal atrial tachycardia (MAT)[18][10]
  • P waves: ≥ 3 distinct P-wave morphologies
  • Rhythm: irregularly irregular
  • PR interval: distinguishable and variable
  • Isoelectric baseline present and distinct [16]
  • Atrial rate > ventricular rate
  • HR > 100

Afib is the most common cause of irregular NCT, followed by atrial tachycardia. MAT is an uncommon cause of tachyarrhythmia; it is often associated with congestive heart failure and COPD. [10][19]

Management of atrial fibrillation with RVR (and atrial flutter) [16][1]

Rate control [16][1]

Avoid CCBs and β-blockers in decompensated heart failure.

Avoid CCBs, digoxin, and adenosine in patients with pre-excitation because of the risk of the arrhythmia converting to ventricular fibrillation.

Rhythm control (e.g., cardioversion) [16][1][23]

Electrical cardioversion

Pharmacological cardioversion for atrial fibrillation [16]

Further management

  • Consider cardiology consultation for long-term therapy, anticoagulation therapy, and consideration of ablation therapy or surgery.
  • Identify and treat the underlying cause.

Management of multifocal atrial tachycardia [10]

Rhythm control is usually ineffective for MAT. [10]

Stable, wide-complex tachycardia

Establishing the underlying rhythm in a patient with wide-complex tachycardia can be extremely challenging and requires a multifaceted approach. The most critical aspect is to distinguish between ventricular tachycardia (VT) and SVT with accessory pathway, but if this cannot be done in a timely manner any wide-complex tachycardia should be treated as VT, as wide-complex tachycardias are most commonly caused by ventricular arrhythmias. Ventricular fibrillation is an unstable rhythm and is not addressed here. [27][10]

Approach

  1. Attach defibrillator pads to the patient.
  2. Ensure that the rhythm is stable.
  3. Check 12-lead ECG and perform a brief, focused history (if there is time).
  4. Determine whether the rhythm is more likely to be ventricular or supraventricular in origin (e.g., Brugada criteria) [1]
  5. Urgent cardiology consultation for definitive rhythm identification, management, and follow-up (see differential diagnoses of wide-complex tachycardia)
  6. Identify and treat the underlying cause (e.g., cardiac glycoside poisoning, myocardial ischemia).

If it is not possible to quickly identify the underlying rhythm as SVT or VT, it is safest to treat empirically as VT with synchronized electrical cardioversion (100 J) or with IV procainamide.

Adenosine and AV nodal blocking agents are contraindicated in unstable, irregular, and polymorphic (e.g., Torsades des pointes) wide-complex tachycardias. In SVT with accessory pathway (e.g., Afib with WPW), the AV blockade caused by adenosine can lead to V-Fib due to unrestricted conduction of rapid atrial impulses through the accessory pathway.

Differentiating between VT and SVT

  • There are multiple tools and strategies available, all with advantages and disadvantages.
  • The Brugada criteria is a commonly used algorithm to differentiate between VT and SVT in regular wide-complex tachycardia. [29]
Brugada criteria [30]
ECG finding VT SVT
Absence of RS in all precordial leads? Yes No
R:S interval > 100 ms in one precordial lead? Yes No
AV dissociation present? Yes No
Morphology consistent with VT in leads V1-2 and V6? Yes No

Interpretation

  • If the answer to any is yes: most likely VT
  • If none are present: most likely SVT

Management of stable, undifferentiated ventricular tachycardia [1][31][32]

Pharmacological cardioversion (IV antiarrhythmics)

Do not administer a second antiarrhythmic without expert consultation. [1]

Adenosine is contraindicated in polymorphic WCT and irregular WCT because of the risk of triggering ventricular fibrillation. Verapamil is contraindicated in WCT because of the risk of profound hypotension and cardiac arrest.

Electrical cardioversion

If it is unclear if a ventricular tachycardia is monomorphic or polymorphic, use defibrillation.

Further management

Differential diagnosis of wide-complex tachycardia

Rhythm Typical ECG findings Acute management
Monomorphic ventricular tachycardia [36][4][1][31]
Polymorphic ventricular tachycardia Undifferentiated polymorphic ventricular tachycardia [36][1][31][37]
  • Rate: 120–300/min
  • Wide QRS complexes with variable morphology
  • Rhythm: usually irregular

Torsades de pointes [1][37][38][31][36]

Brugada syndrome [1][31]
Supraventricular tachycardia (SVT)

SVT with an accessory pathway [12][10][1][41][28]

  • Rate: typically > 200/minute
  • Rhythm: usually irregular
  • Absence of bundle branch block
  • Resting ECG: may show pre-excitation pattern [1]

SVT without an accessory pathway

[42][1][27][43]

  • Rhythm: usually regular
  • Rate: rarely > 200/minute, typically 120–150/minute
  • Bundle branch block usually present.
    • RBBB (with left hemiblock or right hemiblock)
    • LBBB
  • See management of stable, narrow-complex tachycardia
  • Administer adenosine with caution and under continuous cardiac monitoring.
Ventricular pacing (e.g., pacemaker-induced) [44][45][46][47]
  • Pacing spikes are typically present but may be buried.
  • Sensor-driven tachycardia : rate usually ≤ 160–180/minute
  • Pacemaker-mediated tachycardia : rate usually ≤ 160–180/minute
  • Runaway pacemaker : rate usually ≥ 150–200/minute
  • Place a magnet over the pacemaker.
  • Cardiology consult for pacemaker interrogation and troubleshooting
  • Urgent replacement for runaway pacemaker
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last updated 05/21/2020
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