Irregular SVT

By far the commonest cause of irregular SVT is atrial fibrillation, where the atrial rate is in the region of 450 to 600/min, and the atria really do not contract rhythmically at all. The atrium "fibrillates", writhing like a bag of worms. The conventional view of the pathogenesis of AF is that there are multiple re-entrant `wavelets' moving through the atrial muscle, but recent evidence suggests that much AF actually arises from ectopic activity in the muscular cuff surrounding the pulmonary veins where they enter the left atrium. AF is thought to beget further AF through "electrical remodelling" --- electrophysiological changes that are induced in atrial myocytes due to fast rates and the consequent calcium loading Note that in the above tracing of AF, the ventricular response rate seems rather slow, so we suspect that AV block has been increased using pharmacological manipulation. In uncontrolled AF, rates of about 130 or more are common. Other causes of irregular SVT are:

Frequent atrial extrasystoles; Multifocal atrial tachycardia, where there are three or more distinct atrial foci, combined with tachycardia. There is often severe underlying disease (e.g. chronic obstructive airways disease), and in the ICU setting, MAT has a poor prognosis. "Atrial flutter with variable block".

Although it looks like atrial fibrillation, the above image actually shows multifocal atrial tachycardia. Note how there are at least three different P wave configurations!