Atrial Tachycardia Differential Diagnoses

  • Author: Adam S Budzikowski, MD, PhD; Chief Editor: Jeffrey N Rottman, MD   more...
 
Updated: Mar 29, 2011
 
 

Diagnostic Considerations

The differential diagnosis of atrial tachycardia is the differential diagnosis of supraventricular (SVT) and includes the following:

  • Sinus tachycardia
  • Atrial tachycardia
  • Atrial flutter
  • Atrial fibrillation
  • AV junction–dependent reentrant tachycardias (AV nodal reentrant tachycardia and AV reentrant tachycardia using an accessory pathway)

Differentiating among these diagnoses requires ECG analysis of the tachycardia for P wave activity. The ECG of an SVT typically has narrow QRS complexes (unless aberrant conduction with typical left or right bundle-branch block occurs or bystander preexcitation is seen).

Assessment of the P waves and their relationship to the QRS complex (R waves) may reveal 2 different observations, as follows:

  • In short RP (P wave immediately following the QRS) SVT, the differential diagnosis includes typical AV nodal reentrant tachycardia and AV reentrant tachycardia using accessory pathways and atrial tachycardia with long I°AV block or atrial tachycardia originating from the os of the coronary sinus or junctional tachycardia. To determine the diagnosis requires additional maneuvers such as vagal stimulation (eg, carotid sinus massage, Valsalva) or adenosine.
  • In long RP interval (interval wave preceding QRS) SVT, the differential diagnosis includes atypical (fast-slow) AV nodal reentrant tachycardia and permanent junctional reciprocating tachycardia (PJRT) due to a slowly conducting retrograde accessory pathway, sinus tachycardia, sinus node reentry, atrial tachycardia, atrial flutter, or atrioventricular reentrant tachycardia. Diagnosis requires assessment of the patient condition, vagal maneuvers, adenosine, and cardioversion—namely, procedures that may not only be diagnostic but also therapeutic.

For multifocal atrial tachycardia, the differential diagnosis includes atrial fibrillation because both can manifest with an irregular pulse. Multifocal atrial tachycardia with aberration or preexisting bundle branch block may be misinterpreted as ventricular tachycardia.

The full clinical presentation must be always considered. New-onset atrial tachycardias by themselves are relatively benign. However, if the patient also has new problems (eg, chest pain, unexplained dyspnea, inappropriate hypotension) or a recent illness, perform a more extensive workup because atrial tachycardia may not be the primary problem; acute pulmonary embolus, acute noncardiac illness, thyroid disease, or drugs (especially sympathomimetics or bronchodilators) can cause atrial tachycardia. In addition, with frequent or incessant tachycardia, tachycardia-induced cardiomyopathy may develop.

Differential Diagnoses

Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Adam S Budzikowski, MD, PhD  Assistant Professor of Medicine, Division of Cardiovascular Medicine, Electrophysiology Section, State University of New York Downstate Medical Center, University Hospital of Brooklyn

Adam S Budzikowski, MD, PhD is a member of the following medical societies: European Society of Cardiology, Heart Rhythm Society, and Polish Society of Cardiology

Disclosure: Boston Scientific Consulting fee Consulting; St. Jude Medical Honoraria Speaking and teaching; Zoll Honoraria Speaking and teaching

Coauthor(s)

Paul Blackburn, DO, FACOEP, FACEP  Attending Physician, Department of Emergency Medicine, Maricopa Medical Center

Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association

Disclosure: Nothing to disclose.

Robin R Hemphill, MD, MPH  Associate Professor, Director, Quality and Safety, Department of Emergency Medicine, Emory University School of Medicine

Robin R Hemphill, MD, MPH is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Edmond A Hooker II, MD, DrPH, FAAEM  Assistant Professor, Department of Emergency Medicine, University of Cincinnati College of Medicine

Edmond A Hooker II, MD, DrPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Public Health Association, Society for Academic Emergency Medicine, and Southern Medical Association

Disclosure: Nothing to disclose.

Michael A Huott, MD  Consulting Staff, Department of Emergency Medicine, Southwest Texas Methodist Hospital

Disclosure: Nothing to disclose.

Pratap C Reddy, MD  Joe E Holoubek Professor of Medicine, Professor of Anesthesiology, Louisiana State University School of Medicine in Shreveport

Pratap C Reddy, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Federation for Medical Research, American Heart Association, and American Medical Association

Disclosure: Nothing to disclose.

Neeraj Tandon, MBBS  Chief, Cardiology Section, Associate Professor of Medicine, Medical Service, Overton Brooks Veterans Affairs Medical Center

Neeraj Tandon, MBBS is a member of the following medical societies: American College of Cardiology and Society of Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Specialty Editor Board

Justin D Pearlman, MD, PhD, ME, MA  Director of Advanced Cardiovascular Imaging, Professor of Medicine, Professor of Radiology, Adjunct Professor, Thayer Bioengineering and Computer Science, Dartmouth-Hitchcock Medical Center

Justin D Pearlman, MD, PhD, ME, MA is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Federation for Medical Research, International Society for Magnetic Resonance in Medicine, and Radiological Society of North America

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Brian Olshansky, MD  Professor of Medicine, Department of Internal Medicine, University of Iowa College of Medicine

Brian Olshansky, MD is a member of the following medical societies: American Autonomic Society, American College of Cardiology, American College of Chest Physicians, American College of Physicians, American College of Sports Medicine, American Federation for Clinical Research, American Heart Association, Cardiac Electrophysiology Society, Heart Rhythm Society, and New York Academy of Sciences

Disclosure: Guidant/Boston Scientific Honoraria Speaking and teaching; Medtronic Honoraria Speaking and teaching; Guidant/Boston Scientific Consulting fee Consulting; Novartis Honoraria Speaking and teaching; Novartis Consulting fee Consulting

David FM Brown, MD  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital

David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Jeffrey N Rottman, MD  Professor of Medicine and Pharmacology, Vanderbilt University School of Medicine; Chief, Department of Cardiology, Nashville Veterans Affairs Medical Center

Jeffrey N Rottman, MD is a member of the following medical societies: American Heart Association and North American Society of Pacing and Electrophysiology (NASPE)

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Li Zhou, MD, Grzegorz Rozmus, MD, James P Daubert, MD, David Huang, MD, Andrzej M Okreglicki, MB, ChB, MMed, Hongsheng M Guo, MD, and Dariusz Michałkiewicz, MD, to the development and writing of the source articles.

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Propagation map of right atrial tachycardia originating from the right atrial appendage obtained with non-contact mapping using Ensite mapping system.
This 12-lead electrocardiogram demonstrates an atrial tachycardia at a rate of approximately 150 beats per minute. Note the negative P waves in leads III and aVF (upright arrows) are different from the sinus beats (downward arrows). The RP interval exceeds the PR interval during the tachycardia. Note also that the tachycardia persists despite the atrioventricular block.
Note that the atrial activities originate from the right atrium and persist despite the atrioventricular block. These features essentially exclude atrioventricular nodal reentry tachycardia and atrioventricular tachycardia via an accessory pathway. Note also that the change in the P wave axis at the onset of tachycardia makes sinus tachycardia unlikely.
Anterior-posterior projection is shown. An example of activation mapping using contact technique and EnSite system. The atrial anatomy is partially reconstructed. Early activation points are marked with white/red color. The activation waveform spreads from the inferior/lateral aspect of the atrium thought the entire chamber. White points indicate successful ablation sites that terminated the tachycardia. TV – Tricuspid valveCS – Shadow of the catheter inserted in the coronary sinus
Intracardiac tracings showing atrial tachycardia breaking with application of radiofrequency energy. The local electrograms in the successful site preceded the surface P wave by 51 ms, consistent with successful site. Note that postablation electrograms on the ablation catheter is inscribed well past the onset of sinus rhythm P wave. The first 3 tracings show surface electrocardiograms as labeled.CS – Respective pair of electrodes of the coronary sinus catheterCS 7,8 – Located at the os of the coronary sinusCS 1,2 – Distal pair of electrodes Abl – Ablation catheter (D-distal pair of electrodes)
An example of rapid atrial tachycardia mimicking atrial flutter. Single radiofrequency application terminates the tachycardia. The first 3 tracings show surface electrocardiograms, as labeled. HRA – High right atrial catheterRVA – Catheter located in right ventricular apexHBED and HBEP – Respectively, distal and proximal pair of electrodes in the catheter located at His bundleAblD and AblP – Respectively, distal and proximal pair of electrodes of the mapping catheterMAP – Unipolar electrograms from the tip of the mapping catheter
ECG showing multifocal atrial tachycardia (MAT).
 
 
 
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