What is an arrhythmia?
An arrhythmia (also called dysrhythmia) is an irregular or abnormal heartbeat. The cardiac rhythm specialist will recommend the treatment depending on the type and severity of the arrhythmia.
Supraventricular tachycardia means arrhythmia originating from the upper 2 chambers of the heart (right and left atrium).
Atrioventricular nodal reentrant tachycardia (AVNRT)
Medical Treatment
Healthcare providers can treat acute episodes of AVNRT fairly quickly and easily. First, they generally guide the patient through a few attempts at increasing their vagal tone.
If that fails to stop the arrhythmia, an intravenous injection of adenosine or verapamil (a calcium channel blocker) will usually work quickly and reliably. The more difficult medical question pertains to long-term therapy for AVNRT.
Though the arrhythmia is life-disrupting, it is not life-threatening. As such, the aggressiveness of treatment ought to reflect the extent of the impact of symptoms on the patient.
If episodes are quite infrequent, reasonably well-tolerated, and can be terminated pretty reliably by vagal maneuvers, then likely nothing more needs to be done.
However, if episodes of AVNRT are disruptive to a patient's life, which is often the case, then treatment ought to be strongly considered. Treatment with beta-blockers or calcium channel blockers is variably effective in reducing the frequency of AVNRT. In most patients, these drugs have few side effects.
If the arrhythmia is not sufficiently controlled, then one of the antiarrhythmic drugs might be tried. However, these drugs often have side effects, and they are only moderately effective in treating AVNRT.
The most effective means of treating AVNRT today is to use ablation therapy, a catheterization procedure. With ablation therapy, the abnormal electrical connection in or near the AV node is carefully mapped and then is ablated, usually with radiofrequency energy.
AVNRT can be completely cured with ablation therapy in over 95% of cases. It should be strongly considered by anyone in whom AVNRT is a major problem, especially if it has not been controlled using beta-blockers or calcium blockers.
Invasive Therapies
Electrical cardioversion
In patients with persistent atrial arrhythmia like atrial fibrillation, a normal rhythm may not be achieved with drug therapy alone. Resetting the sinus rhythm can be achieved with electrical cardioversion. Cardioversion is performed by the physician in a special room after administration of the short acting anesthesia. An electrical impulse is delivered through your chest wall that synchronizes the heart and allows the normal rhythm to restart. This is mostly a temporary solution and need more medication and/or ablation to maintain the sinus rhythm.
Catheter ablation
During the catheter ablation, radio-frequency electrical energy (RF ablation) is delivered through a catheter to a small area of tissue inside of the heart that causes the abnormal heart rhythm. This energy "disconnects" the pathway of the abnormal rhythm. Ablation can be used to treat most SVTs, atrial flutter, and some atrial and ventricular tachycardias.
Pulmonary vein isolation
In patients with frequent, paroxysmal or persistent atrial fibrillation, isolation of the pulmonary veins is a type of ablation that targets areas thought to cause atrial fibrillation. The goal is to create rings of scar that isolate the foci responsible for triggering atrial fibrillation.
Focal Atrial Tachycardia (AT)
A focal atrial tachycardia is an arrhythmia with electrical impulses originating and confined within the upper chambers of the heart (atria). Focal tachycardia typically occurs in the setting of increased metabolic demand and stress, like infection, hypoxia, etc. Focal atrial tachycardia generally is a benign arrhythmia. That said, focal atrial tachycardia requires differentiation from other atrial arrhythmias, like atrial fibrillation and atrial flutter. Appropriate diagnosis of focal atrial tachycardia must be made to guide proper management.
Atrial tachycardia tends to occur in individuals with structural heart disease, with or without heart failure, and ischemic coronary artery disease. However, focal atrial tachycardia often occurs in healthy individuals without structural heart disease.
The symptoms of atrial tachycardia are palpitations or sensations of fast heart rate, lightheadedness, chest pain or pressure, or shortness of breath. Symptom intensity will be related to the rate as well as the patient’s cardiovascular status.
Symptoms may occur in paroxysms or can be persistent. Symptoms may be related to the consumption of caffeinated products (including coffee, tea, energy drinks or chocolate) or stimulants like ephedrine. Symptoms can also be initiated or exacerbated by stress and exercise.
Persistent focal atrial tachycardia can result in cardiomyopathy, which may lead to symptoms of dyspnea with exertion, increased lower extremity edema, and chest pain.
Atrial Flutter
Images and videos of procedure involving multiple atrial flutters
The atrial flutter is an arrhythmia with electrical impulses originating within the upper chamber of the heart (atria). Atrial flutter can be a result of macro-reentry as the mechanism leading to arrhythmia: Typical atrial flutter arises from the right atrium in a circuit bound anteriorly by the tricuspid annulus and posteriorly by the crista terminalis and Eustachian ridge. The electrical activity can travel in a clockwise or counterclockwise direction in this circuit.
Atrial flutter is a complex arrhythmia with different management than other atrial arrhythmias. Like atrial fibrillation, the atrial flutter can cause stroke due to thrmbo-embolic event.
The atypical atrial flutter is seen to occur in individuals with structural heart disease, prior cardiac surgery or ablation procedure.
Persistent atrial flutter can result in cardiomyopathy, which may lead to symptoms of dyspnea with exertion, increased lower extremity edema, and chest pain.
Management
Initial management of atrial flutter is to initiate anticoagulants depending on their risk of stroke. The use heart rate controlling medications like beta blockers or calcium channel blockers. If atrial flutter persists and the patient is symptomatic, the patient may benefit from class IA, IC, or class III antiarrhythmics. Of course, risks and benefits of using antiarrhythmic medications should be considered, especially in patients with ischemic or structural heart disease.
The atrial flutter can be cured with ablation procedure with success rate of above 95%. The atrial flutters can be resistant to medications and can cause recurrences due to the reentrant mechanism. Electrical cardioversion can be used with anti- arrhythmic medications while waiting for the ablation procedure.
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