eMedicine Specialties > Cardiology > Arrhythmias

Paroxysmal Supraventricular Tachycardia: Differential Diagnoses & Workup

Author: Monika Gugneja, MD, Consulting Staff, Department of Emergency Medicine, William Beaumont Hospital
Coauthor(s): Phillip L Kraft, MD, Director, Interventional Cardiology and Cardiac Catheterization Laboratory, William Beaumont Hospital
Contributor Information and Disclosures

Updated: Aug 12, 2009

Differential Diagnoses

Atrial Fibrillation
Ventricular Fibrillation
Atrial Flutter
Ventricular Tachycardia
Atrial Tachycardia
Atrioventricular Nodal Reentry Tachycardia (AVNRT)
Sinus Node Dysfunction

Workup

Laboratory Studies

  • A cardiac enzyme evaluation should be ordered for patients with chest pain; patients with risk factors for myocardial infarction; and patients who are otherwise unstable and present with heart failure, hypotension, or pulmonary edema. Young patients with no structural heart defects have a very low risk of myocardial infarction.
  • Electrolyte levels should be checked because electrolyte abnormalities can contribute to paroxysmal supraventricular tachycardia.
  • A complete blood cell count helps assess whether anemia is contributing to the tachycardia or ischemia.
  • The results from thyroid studies are rarely diagnostic of hyperthyroidism.
  • Obtain a digoxin level for patients on digoxin because paroxysmal supraventricular tachycardia is one of the many dysrhythmias that can be caused by supratherapeutic levels of this drug.

Imaging Studies

  • Obtain a chest radiograph to assess for the presence of pulmonary edema and cardiomegaly. Infections such as pneumonia, which are associated with paroxysmal supraventricular tachycardia in certain cases, can also be confirmed with findings from this imaging method.20,39,55,48,24 Congenital heart defects such as Ebstein anomaly of the tricuspid valve can be suspected.
  • A transthoracic echocardiogram may be helpful if structural or congenital heart disease is suggested. Cardiac MRI can be useful, especially if a congenital heart disease is being considered.

Other Tests

ECG findings allow classification of the tachyarrhythmia, and they may allow a precise diagnosis. P waves may not be visible; when present, they may be normal or abnormal depending on the mechanism of atrial depolarization.20,34,55

  • ECG characteristics of the various SVTs are as follows:
    • Sinus tachycardia - Heart rate greater than 100 bpm; P waves similar to sinus rhythm
    • Inappropriate sinus tachycardia - Findings similar to sinus tachycardia; P waves similar to sinus rhythm
    • Sinus node reentrant tachycardia - P waves similar to sinus rhythm; abrupt onset and offset
    • Atrial tachycardia - Heart rate 120-250 bpm; P-wave morphology different from sinus rhythm; long RP interval (in general); AV block does not terminate tachycardia
    • Multifocal atrial tachycardia - Heart rate 100-200 bpm; 3 or more different P-wave morphologies
    • Atrial flutter- Atrial rate of 200-300 bpm; flutter waves; AV conduction of 2:1 or 4:1
    • Atrial fibrillation - Irregularly irregular rhythm; lack of discernible P waves
    • AV nodal reentrant tachycardia - Heart rate of 150-200 bpm; P wave located either within the QRS complex or shortly after the QRS complex; short RP interval in typical AVNRT and long RP interval in atypical AVNRT
    • AV reentrant tachycardia - Heart rate of 150-250 bpm; narrow QRS complex in orthodromic conduction and wide QRS in antidromic conduction; diagnosis excluded by AV block during SVT; P wave after QRS complex
  • Following the termination of the tachycardia, an ECG should be performed during the sinus rhythm to screen for WPW syndrome. Echocardiography and/or Holter monitoring also may be useful. These tests can help assess the frequency and duration of SVT episodes, although they have a low yield. Echocardiography may be helpful in screening for structural or congenital heart disease.
  • Characterizing the SVT by comparing the RP interval to the PR interval is helpful. Long RP tachycardias result when atrial activity precedes the QRS complex. In short RP tachycardias, atrial activity occurs with or shortly after ventricle excitation. In short RP tachycardias, the P wave is found within the QRS complex or shortly after the QRS complex.20,39,55,48 The classifications of SVTs based on the RP interval are as follows:
    • Short RP tachycardias – Typical AVNRT, AVRT, JET, and NPJT
    • Long RP tachycardias – Sinus tachycardia, SNRT, atrial tachycardia, atrial flutter, atypical AVNRT, and a permanent form of junctional reciprocating tachycardia

Procedures

  • Electrophysiology studies have dramatically changed the diagnosis of SVT. Intracardiac recordings have helped map accessory pathways and reentry circuits in patients, and they have also assisted cardiologists and electrophysiologists in understanding the mechanisms behind these tachyarrhythmias.
  • At present, electrophysiologic studies are generally performed in combination with radiofrequency catheter ablation. Catheter ablation is indicated in patients with severe symptoms, symptomatic preexcitation syndrome, incessant tachycardia, and those who do not tolerate or do not desire medical therapy. Catheter ablation procedures are generally performed in an outpatient setting or with an overnight stay for observation.

More on Paroxysmal Supraventricular Tachycardia

Overview: Paroxysmal Supraventricular Tachycardia
Differential Diagnoses & Workup: Paroxysmal Supraventricular Tachycardia
Treatment & Medication: Paroxysmal Supraventricular Tachycardia
Follow-up: Paroxysmal Supraventricular Tachycardia
Multimedia: Paroxysmal Supraventricular Tachycardia
References
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Further Reading

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Keywords

paroxysmal supraventricular tachycardia, PSVT, supraventricular tachycardia, SVT, multifocal atrial tachycardia, MAT, tachyarrhythmia, atrial fibrillation, AF, conduction pathway disturbance, conduction pathway abnormality, conduction pathway anomaly, dysrhythmia, heart condition, heart rhythm problem, atrial tachyarrhythmia, atrioventricular tachyarrhythmia, AV tachyarrhythmia, sinus tachycardia, inappropriate sinus tachycardia, IST, sinusnodal reentranttachycardia, SNRT, atrial tachycardia, atrial flutter, AV tachyarrhythmias, AV nodal reentrant tachycardia, atrioventricular nodal reentrant tachycardia, AVNRT, atrioventricular reentrant tachycardia, AV reentrant tachycardia, AVRT, junctional ectopic tachycardia, JET, nonparoxysmal junctional tachycardia, NPJT, heartfailure, pulmonary edema, myocardial ischemia, myocardial infarction, syncope, sudden death, tachycardia-induced cardiomyopathy, WPW syndrome

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Contributor Information and Disclosures

Author

Monika Gugneja, MD, Consulting Staff, Department of Emergency Medicine, William Beaumont Hospital
Disclosure: Nothing to disclose.

Coauthor(s)

Phillip L Kraft, MD, Director, Interventional Cardiology and Cardiac Catheterization Laboratory, William Beaumont Hospital
Phillip L Kraft, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, and Michigan State Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Alan D Forker, MD, Professor of Medicine, Program Director of Cardiovascular Fellowship, University of Missouri at Kansas City School of Medicine; Director, Outpatient Lipid Diabetes Research Center, MidAmerica Heart Institute of St Luke's Hospital
Alan D Forker, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, American Society of Hypertension, and Phi Beta Kappa
Disclosure: Research Grant Grant/research funds Hospital contracts to do research; I am a hospital employee with no personal profit; Speakers Bureau Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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; Reliant Grant/research funds Other; Novartis Honoraria Speaking and teaching; Novartis Consulting fee Consulting

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Michael E Zevitz, MD, Assistant Professor of Medicine, Finch University of the Health Sciences, The Chicago Medical School; Consulting Staff, Private Practice
Michael E Zevitz, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Medical Association, and Michigan State Medical Society
Disclosure: Nothing to disclose.

 
 
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