A 35 year old female presents to the emergency department with a complaint of

palpitations for 2 hours. She states that she has intermittently had palpitations for years,
but always lasting for minutes only. These palpitations are associated with mild dizziness
and shortness of breath. No chest pain occurs.

Her temperature is 37.0, blood pressure 90/50, heart rate 190, respiratory rate is 16. No
jugular venous distension is present, she is tachycardic and regular on cardiac exam
without any murmurs. Her lungs are clear to auscultation. The rest of her exam is
normal. Her ECG is below.

What are the findings of this ECG tracing?

1. Narrow complex "short-RP" tachycardia - most likely AV nodal reentry

tachycardia (AVNRT)

The ECG shows a narrow-complex tachycardia that is regular (remember atrial fibrillation
would be irregular). No flutter waves are seen. In leads V3 - V6 a P wave can be seen
just after the QRS complex making this rhythm a "short-RP" tachycardia. Remember the
most common short-RP tachycardia is AV nodal reentry tachycardia (AVNRT).

What is the electrophysiologic mechanism present that predisposes her for this
arrhythmia?

AVNRT is due to a congenital abnormality within the AV node that allows for a re-entrant
tachycardia. In those susceptible to AVNRT, two conduction pathways exist within the AV
node. One pathway conducts fast and has a long refractory period while the second
pathway conducts slowly and has a short refractory period. When an ectopic beat occurs
(a premature atrial contraction or premature ventricular contraction), a re-entrant loop
can be triggered resulting in this narrow-complex tachyarrhythmia.

What would be the trement for this patient? Include non-medical therapy,
medical therapy and any other intervention that can be effectively used.

No therapy is episodes are brief and symptoms mild, vagal maneuvers, adenosine to
terminate a persistent episode, AV blocking agents and eventually catheter ablation if
refractory to the above.

Explaination: In most cases, AVNRT will spontaneously terminate with no intervention.

Simply reducing the amount of sympathetic nervous system stimulation by having the
patient relax or by giving sedation may be effective. The re-entrant pathway can be
interrupted by blocking the AV node enough to restore sinus rhythm. Enhancing vagal
tone by specific maneuvers (Valsalva, carotid massage, ice on face) can cause a
physiologic AV blocking affect and terminate the tachycardia. Any of the AV blocking
medications may also work (remember the mneumonic "ABCD" for AV blocking agents:
Adenosine, Beta-blockers, Calcium channel blockers, Digoxin). Usually adenosine is used
in the emergency room due to its short half-life. Very rarely is electrical cardioversion
needed. If the severity and frequency of attacks decrease the patient's quality of life,
catheter ablation can be performed to eliminate one of the dual pathways and is > 90%
affective in preventing future episodes of AVNRT.