What is supraventricular tachycardia. Supraventricular tachycardia with bundle branch block. Differential diagnosis of ventricular and supraventricular tachycardia

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2013

Other specified cardiac arrhythmias (I49.8), Supraventricular tachycardia (I47.1), Preexcitation syndrome (I45.6)

Cardiology

general information

Short description

Approved by the minutes of the meeting
Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan
No. 23 dated 12/12/2013

Abbreviations used in the protocol:

AB - atrioventricular

VT - ventricular tachycardia

BIT - intensive care unit

SVT - supraventricular tachycardia

PT - atrial tachycardia

TPSS - transesophageal stimulation of the heart

EKS - pacemaker

ECG - electrocardiography

HR - heart rate

WPW-Wolff-Parkinson-White

EIT - electropulse therapy

ACC - American College of Cardiology

ABYPT - atrioventricular nodal reciprocal tachycardia

RFA - radiofrequency ablation

EchoCG - echocardiography

FGDS - fibrogastroduadenoscopy

EFI - electrophysiological study

Protocol Users: cardiologists, pediatricians, resuscitators, cardiac surgeons, interventional cardiologists, interventional arrhythmologists, therapists, general practitioners.

Classification

Clinical classification
Depending on the localization, there are:
- Sinus tachycardia
- Atrial tachycardia
- Atrioventricular tachycardia

Depending on the mechanism of occurrence of arrhythmia, there are:
- Re-entry phenomenon of re-entry of the excitation wave
a. Micro re-entry
b. Macro re-entry
- Focal arrhythmia:
1. Anomalous automatism
a. increased normal automatism
b. abnormal automatism
2. Trigger activity
a. early post-depolarization
b. late postdepolarization

Depending on the flow, there are:
- Paroxysmal
- Non-paroxysmal

Clinical picture

Symptoms, course

Diagnostic criteria
1) complaints and anamnesis:
Complaints about palpitations, weakness, loss of consciousness, dizziness to fainting, a feeling of lack of air, shortness of breath.

2) Physical examination:
Paroxysmal supraventricular tachycardia has no characteristic physical signs, except for symptoms (palpitations). In young people, symptoms may be minimal even with a high heart rate. In other cases, during an attack, there is a coldness of the extremities, sweating, hypotension, signs of stagnation in the lungs may appear, especially with concomitant heart defects - congenital or acquired. An arrhythmia attack can last from a few seconds to several hours and pass on its own or after reflex techniques.

3) Laboratory research:
- determination of the electrolyte composition of the blood (Na, K, Ca).

4) Instrumental Research
ECG
The main diagnostic method is the ECG.
Supraventricular tachycardia is characterized on the ECG by the following features: heart rate from 100-250 beats per minute. Ventricular complexes during an attack have the same shape and amplitude as outside an attack. Narrow QRS complexes (less than 0.12 sec) are characteristic. A wide QRS complex does not rule out SVT. Ventricular complexes are somehow associated with atrial P waves, in the absence of concomitant AV block. The P wave may precede the ventricular complex, may merge with or follow the QRS complex. The absence of a P wave is possible with reciprocal AV tachycardia (P "hidden" in the QRS complex and does not exclude the diagnosis of SVT. P waves during an attack differ in shape, amplitude, and often in polarity from those recorded in this patient against the background of sinus rhythm.

Diagnostics

The list of basic and additional diagnostic measures:
1. Complete blood count with leukocyte formula and platelet count (test results are valid for 10 days).
2. Urinalysis (the results of the analysis are valid for 10 days).
3. Feces for helminth eggs (test results are valid for 10 days).
4. Biochemical blood test (total protein, urea, creatinine, glucose, cholesterol, ALT, AST, bilirubin, amylase), electrolytes (potassium, sodium, calcium) (test results are valid for 10 days).
5. Coagulogram (fibrinogen, thrombin time; prothrombin time, APTT/APTT) (test results are valid for 10 days).
6. Blood type and Rh factor.
7. Results of radiography of organs chest with a snapshot (the results of the analysis are valid for 12 months).
8. Feces for pathological flora (the results of the analysis are valid for 10 days).
9. FGDS (research results are valid for 30 days).
10. Blood on RW (test results are valid for 30 days).
11. Blood ELISA for markers of hepatitis "B" and "C" (the results of the analysis are valid for 30 days).
12. ELISA of blood for HIV (test results are valid for 30 days).
13. UZDG arteries lower extremities(test results are valid for 30 days).
14. Ultrasound of extracranial vessels (the results of the study are valid for 30 days).
15. Echocardiography (research results are valid for 30 days).
16. ECG (research results are valid for 10 days).
17. Spirometry (research results are valid for 30 days).
18. Consultation of a dentist, ENT doctor (results 30 days).
19. Consultation with a gynecologist (women over 16) (results are valid for 30 days).
20. Additional consultations of specialized specialists in the presence of concomitant pathology.

Diagnostic criteria :

Complaints and anamnesis:
The subjective tolerance of paroxysmal supraventricular tachycardias (PNT) largely depends on the severity of tachycardia: with a heart rate (HR) of more than 130-140 beats / min, paroxysm rarely remains asymptomatic. However, sometimes patients do not feel paroxysmal tachycardia, especially if the heart rate during an attack is low, the attack is short, and the myocardium is intact. Some patients perceive the heartbeat as moderate, but feel weakness, dizziness and nausea during an attack. Generalized manifestations of autonomic dysfunction (trembling, chills, sweating, polyuria, etc.) in PNT are less pronounced than in attacks of sinus tachycardia.
The clinical picture to some extent depends on the specific type of arrhythmia, however, complaints of a completely sudden onset of an attack are common to all PNT. palpitations. The rate of heart contractions, as it were, instantly switches from normal to very fast, which is sometimes preceded by a more or less long period of feeling interruptions in the work of the heart (extrasystole). The end of an attack of PNT is as sudden as its onset, regardless of whether the attack stopped on its own or under the influence of drugs.
Features of the clinical picture during an attack of PNT depend on a number of factors: the presence or absence of a "background" organic heart disease, the state of contractile myocardium and coronary blood flow, the location of the ectopic pacemaker, heart rate, and the duration of the attack. The higher the heart rate, the more pronounced the clinical picture is usually. With very prolonged attacks, in most cases, heart failure develops. vascular insufficiency. If PNT appears in a patient with severe myocardial damage (heart attack, congestive cardiomyopathy), cardiogenic (arrhythmogenic) shock may develop already in the first minutes after the onset of an attack. Also dangerous are such hemodynamic disturbances that sometimes occur against the background of PNT, such as disorders of consciousness up to syncope, Morgagni-Adams-Stokes attacks. Syncope occurs in about 15% of cases of PNT and usually occurs either at the onset of the attack or after it has ended. Some patients experience anginal pain during an attack (most often with coronary heart disease); shortness of breath often develops (acute heart failure - up to pulmonary edema).
The frequency and duration of attacks vary widely. Short "runs" of PNT (several consecutive ectopic complexes) are often not felt by the patient or are perceived as interruptions. Sometimes a patient suffers a single, but prolonged (many hours) attack of PNT for many years of his life. And sometimes tachycardia is of a “recurrent” nature - with short, often recurring paroxysms that can be felt non-specifically: weakness, a feeling of lack of air, a feeling of interruptions in the work of the heart. Between these extreme options there are many intermediate forms. Recurrent episodes of PNT are characteristic, which clinically proceed in the same way, although paroxysms often become more frequent and lengthen over time, are worse tolerated, and sometimes, on the contrary, become rarer and shorter, or even stop altogether.

Diagnostics
Suspicion of paroxysmal supraventricular tachycardia (PVT) should arise if the patient suddenly (as if on a switch) has attacks of palpitations. To confirm the diagnosis, a physical examination and instrumental diagnostics are performed, the main method of which is electrocardiography (ECG).

Collection of anamnesis:
For a preliminary diagnosis of paroxysmal supraventricular tachycardia, in most cases, it is enough to take an anamnesis: the presence of a completely sudden (“as if by pressing a switch”) onset of an attack of a sharp heartbeat is an extremely characteristic sign. It is very important to find out from the patient whether the change in rhythm really occurs instantly. Many patients believe that their palpitations occur suddenly, but a more detailed questioning allows us to establish that in fact the increase in heart rate occurs gradually, over several minutes. This picture is typical for episodes of sinus tachycardia.
In differential diagnosis, if a patient has tachycardia with wide QRS complexes, it should be remembered that, other things being equal, patients tolerate supraventricular (atrial and atrioventricular) paroxysmal supraventricular tachycardia (PNT) more easily than ventricular tachycardia. In addition, the incidence of ventricular tachycardia increases significantly with age; in relation to supraventricular PNT, this pattern is absent. PNT is much more likely than ventricular tachycardia to have a pronounced vegetative color (sweating, feeling of internal trembling, nausea, frequent urination). The stopping effect of vagal tests is extremely characteristic.

Physical examination:
Auscultation during an attack revealed frequent rhythmic heart sounds; A heart rate of 150 beats/min and above excludes the diagnosis of sinus tachycardia, a heart rate of more than 200 makes ventricular tachycardia unlikely. One should be aware of the possibility of atrial flutter with a conduction ratio of 2:1, in which vagal tests can lead to a short-term deterioration in conduction (up to 3:1, 4:1) with a corresponding abrupt decrease in heart rate. If the duration of systole and diastole become approximately equal, the second tone becomes indistinguishable from the first in volume and timbre (the so-called pendulum rhythm, or embryocardia). Most paroxysmal supraventricular tachycardias (PNT) are characterized by rhythm rigidity (its frequency is not affected by intensive breathing, physical activity, etc.).
However, auscultation does not allow to find out the source of tachycardia, and sometimes to distinguish sinus tachycardia from paroxysmal.
The pulse is frequent (often it can not be counted), soft, weak filling.
Occasionally, for example, with a combination of paroxysmal supraventricular tachycardia (PNT) and atrioventricular blockade of the II degree with Samoilov-Wenckebach periods or with chaotic (multifocal) atrial tachycardia, the regularity of the rhythm is disturbed; at the same time, a differential diagnosis with atrial fibrillation is possible only by ECG.
Blood pressure usually goes down. Sometimes an attack is accompanied by acute left ventricular failure (cardiac asthma, pulmonary edema).

Laboratory research:
Determination of the electrolyte composition of the blood.
Arterial blood gases (for pulmonary edema, confusion, or signs of sepsis)

Instrumental research:

ECG:
The main diagnostic method is the ECG.
Paroxysmal supraventricular tachycardia (PNT) is typically characterized on the ECG by the following features:
Stable right rhythm with heart rate from 140-150 to 220 beats / min. With a heart rate of less than 150 beats / min, sinus non-paroxysmal tachycardia is more likely. With a very high frequency of supraventricular tachycardia or a latent violation of atrioventricular conduction during an attack, an atrioventricular blockade of the II degree often develops with Samoilov-Wenckebach periods or a loss of every second ventricular contraction.
Ventricular complexes during an attack have the same shape and amplitude as outside an attack. Narrow QRS complexes (less than 0.12 sec) are characteristic. A wide QRS complex does not exclude PNT: sometimes, in the presence of latent conduction disturbances in the branches of the intraventricular conduction system, during an attack of supraventricular tachycardia, the ventricular QRS complexes are deformed and widened, usually as a complete blockade of one of the legs of the His bundle. Deformation of the QRS complex (pseudo R-wave in lead V1 or pseudo S-wave in leads II, III, aVF) may be due to the imposition of the P wave on it in AV nodal tachycardia.
Ventricular complexes are somehow associated with atrial P waves. The relationship of QRS complexes with atrial P waves can be different: the P wave may precede the ventricular complex (and the PQ interval is always greater or less than in sinus rhythm), may merge with the QRS complex, or follow him. The P wave must be actively sought (it can overlap with the QRS complex or the T wave, deforming them). Sometimes it does not differentiate, completely merging with the T wave of the previous ventricular complex or superimposed on the T wave following the QRS complex (as a result of slowing down retrograde conduction with AV block). The absence of a P wave is possible with reciprocal AV tachycardia (P "hidden" in the QRS complex) and does not exclude the diagnosis of PNT.
The P waves during an attack differ in shape, amplitude, and often in polarity from those recorded in this patient against the background of sinus rhythm. Inversion of the P wave during an attack most often indicates an atrioventricular genesis of tachycardia.

Holter monitoring:
Holter monitoring allows you to fix frequent paroxysms (including short ones - 3-5 ventricular complexes - "runs" of PNT, subjectively not perceived by the patient or felt as interruptions in the work of the heart), assess their beginning and end, diagnose transient ventricular preexcitation syndrome and concomitant arrhythmias . Reciprocal arrhythmia is characterized by the beginning and end of an attack after supraventricular extrasystoles; a gradual increase in the frequency of the rhythm at the beginning of the paroxysm ("warming up") and a decrease - at the end - indicate the automatic nature of tachycardia.

Stress ECG tests
For the diagnosis of PNT are usually not used - a provocation of a paroxysm is possible. If it is necessary to diagnose CAD in a patient with a history of syncope, it is preferable to use transesophageal cardiac pacing (TEPS).

Can be used even in patients with poor tolerance PNT, as it is well stopped by extra stimuli. Indicated for:
1. Clarification of the mechanism of tachycardia.
2. Detection of PNT in patients with rare seizures that cannot be registered "catch" on the ECG.
3. Intracardiac electrophysiological study (EPS)
Allows you to accurately determine the mechanism of PNT and indications for surgical treatment.

NB! Before the study, all antiarrhythmic drugs must be discontinued for at least 5 half-lives. EFI is carried out no earlier than 2 days (in the case of cordarone - 30 days) after the abolition of all cardiotropic drugs. EFI should be carried out, if possible, without premedication or with minimal sedation of the patient.

Differential Diagnosis

In the apparent absence of organic heart disease in patients with PNT, the following conditions should be excluded:
Sick sinus syndrome (SSS). If it is not detected, PNT therapy can be not only unsuccessful, but also dangerous.
Syndromes of preexcitation of the ventricles. The frequency of detection of WPW syndrome in patients with PNT, according to some data, is up to 70%.

Differential diagnosis of wide complex PNT and ventricular tachycardia
Paroxysmal supraventricular tachycardia (PNT) can occur in the form of wide complex tachycardia (from 0.12 seconds or more). This term is used to define the tactics of patient management in cases where it is difficult to accurately determine the type of arrhythmia by ECG. Differential diagnosis for wide-complex tachycardia is carried out primarily between various supraventricular and ventricular tachycardias, and if it is impossible to completely exclude ventricular tachycardia, treatment is carried out in the same way as with a proven paroxysm of ventricular tachycardia (“to the maximum”). Full list tachycardia, which can occur under the guise of "tachycardia with a wide QRS complex":
1. PNT with aberrant conduction to the ventricles.
2. PNT in combination with the blockade of the leg of p. Gisa.
3. Antidromic supraventricular tachycardia in WPW syndrome.
4. Atrial fibrillation/flutter in WPW syndrome
5. Atrial fibrillation/flutter with aberrant ventricular conduction.
6. Ventricular tachycardia
Atrial fibrillation or atrial flutter with a variable conduction coefficient to the ventricles is characterized by arrhythmia of tachycardia, which, at high heart rate (for example, with pre-excitation syndrome), is visually difficult to determine and must be confirmed by accurate measurement of RR intervals: if fluctuations in their duration from 0.04 sec and above are detected, we are talking about about atrial fibrillation or atrial flutter with a variable coefficient of conduction. If the atrial flutter occurs with a constant conduction coefficient, only the identification of FF waves, the presence of which is confirmed by a transesophageal ECG, can help the diagnosis. Differential diagnosis of wide complex PNT and ventricular tachycardia presents significant difficulties; it is advisable to focus on the Verneckei algorithm

Wernecki algorithm (European Heart Journal 2007 28(5):589-600)


With stable hemodynamics and a relatively low heart rate (HR), vagal tests, as well as a test with intravenous ATP administration (contraindicated in the presence of bronchial asthma, as well as previously established conduction disorders), can also be used for the differential diagnosis of PNT and VT, which are interpreted as follows:
Relief of an attack - paroxysmal supraventricular tachycardia (PNT).
Preservation of atrial tachycardia with an increase in the coefficient of conduction - atrial flutter or ectopic atrial tachycardia.
Gradual slowing of the rhythm with a subsequent increase in frequency - non-paroxysmal tachycardia, ectopic atrial tachycardia.
No change - inadequate dose of ATP or VT. That is, any change in ventricular rate in response to ATP administration excludes the diagnosis of ventricular tachycardia (VT). After exclusion of VT, by comparison with the ECG outside the attack, PNT proper with aberrant conduction can be diagnosed against the background of pre-excitation syndromes or a previous blockade of the pedicle of Hisa.

D differential diagnosis based on ECG signs
For adequate selection of effective therapy, it is necessary to determine the specific type of tachycardia; a brief algorithm for differential diagnosis is presented in the table.
Table - Differential diagnosis of various variants of paroxysmal supraventricular tachycardia (PNT) (A.V. Nedostup, O.V. Blagova, 2006)

* AV nodal reciprocal tachyacrdia refers to the following forms of reentry involving the AV node:
§ AV-nodal tachycardia without the participation of additional ways.
§ Orthodromic AV nodal tachycardia in WPW syndrome.
The most accurate method for determining the genesis, substrate of tachycardia is an intracardiac electrophysiological study.

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Treatment

Purpose of treatment:
Prevention of tachycardia attacks, reducing the risk of sudden cardiac death.

Treatment tactics:
Non-drug treatment:
Relief of an attack of paroxysmal supraventricular tachycardia (PNT).
PNT is characterized by the stopping effect of vagal tests. The Valsalva test is usually the most effective (straining with holding the breath for 20-30 seconds), but deep breathing, squatting, lowering the face into cold water for 10-30 seconds, massage of one of the carotid sinuses, etc. can also be useful. contraindicated in patients with conduction disorders, SSSU, severe heart failure, glaucoma, as well as with severe dyscirculatory encephalopathy and a history of stroke. Massage of the carotid sinus is also contraindicated in case of a sharp decrease in pulsation and the presence of noise over the carotid artery.

NB! The Dagnini-Ashner test (pressure on the eyeballs for 5 seconds) is not recommended due to the high risk of injury to the eyeball.

In the absence of the effect of vagal tests and the presence of severe hemodynamic disorders, emergency relief of the paroxysm is indicated using transesophageal cardiac stimulation (TEPS) or electrical impulse therapy (EIT). CHPSS is also used for intolerance to antiarrhythmics, anamnestic data on the development serious violations conduction during the exit from the attack (with SSSU and AV blockades). With multifocal atrial tachycardia, EIT and HRPS are not used; they are ineffective in ectopic atrial and ectopic AV nodal forms of PNT.
Although for the most effective relief of PNT it is desirable to determine its specific form, in real clinical practice, due to the need for urgent therapeutic measures and possible diagnostic difficulties, it is advisable to focus primarily on algorithms for the relief of tachycardia with narrow and wide QRS complexes - to provide emergency care to a patient with paroxysm supraventricular tachycardia precise definition of its mechanism in most cases is not required.
With paroxysmal supraventricular tachycardia (PNT) with narrow QRS complexes.

Medical treatment:
In the absence of a positive effect of vagal tests, patients with stable hemodynamics begin intravenous administration of antiarrhythmic drugs. It is permissible to use these funds without electrocardiographic control only in critical situations or if there is reliable information that the patient has been repeatedly injected in the past. this remedy and it caused no complications. All ampouled preparations, except for triphosphadenine (ATP), are diluted in 10-20 ml of isotonic sodium chloride solution before administration. The drugs of choice are adenosine (sodium adenosine triphosphate, ATP) or non-hydropyridine calcium channel antagonists.
Adenosine (adenosine phosphate) at a dose of 6-12 mg (1-2 amp. 2% solution) or Sodium adenosine triphosphate (ATP) bolus rapidly at a dose of 5-10 mg (0.5-1.0 ml of 1% solution) only in the intensive care unit under monitor control (exit from PNT is possible through stopping the sinus node for 3-5 seconds or more!).
Verapamil is injected slowly in a stream at a dose of 5-10 mg (2.0-4.0 ml of a 2.5% solution) under the control of blood pressure and rhythm frequency.
Procainamide (Novocainamide) is administered intravenously in a slow stream or drip at a dose of 1000 mg (10.0 ml of a 10% solution, the dose can be increased to 17 mg / kg) at a rate of 50-100 mg / min under the control of blood pressure (with a tendency to arterial hypotension - together with 0.3-0.5 ml of 1% phenylephrine solution (Mezaton) or 0.1-0.2 ml of 0.2% norepinephrine solution (Norepinephrine)) :
Propranolol is injected intravenously at a dose of 5-10 mg (5-10 ml of a 0.1% solution) for 5-10 minutes with a short pause after half the dose is administered under the control of blood pressure and heart rate; with initial hypotension, its administration is undesirable even in combination with mezaton.
Propafenone is administered intravenously in a jet at a dose of 1 mg / kg for 3-6 minutes.
Disopyramide (Ritmilen) - at a dose of 15.0 ml of a 1% solution in 10 ml of saline (if novocainamide was not previously administered).
During the performance of vagal techniques or the introduction of drugs, ECG registration is necessary; response to them can help in the diagnosis, even if the arrhythmia has not stopped. After the introduction of an antiarrhythmic, which was not complicated by the development of bradycardia or arrest of the sinus node, it makes sense to repeat the vagal maneuvers.
Approximate frequency and sequence of administration of drugs:
1. Sodium adenosine triphosphate (ATP) 5-10mg IV in push, bolus.
2. No effect - after 2 minutes ATP 10mg IV in a push.
3. No effect - after 2 minutes verapamil 5 mg IV.
4. No effect - after 15 minutes verapamil 5-10 mg IV.
5. Repeat vagal maneuvers.
6. No effect - after 20 minutes novocainamide, or propranolol, or propafenone, or disopyramide - as indicated above; however, in many cases, hypotension is exacerbated and the likelihood of bradycardia after restoration of sinus rhythm increases.

An alternative to the repeated use of the above drugs can be the introduction of:
Amiodarone (Cordarone) at a dose of 300 mg bolus for 5 minutes or drip, however, taking into account the delay of its action (up to several hours), as well as the effect on conductivity and QT duration, which may prevent the introduction of other antiarrhythmics. A special indication for the introduction of amiodarone is paroxysmal tachycardia in patients with ventricular preexcitation syndromes.
Etacizin (Etacizin) 15-20 mg IV for 10 minutes, which, however, has a pronounced proarrhythmic effect, and also blocks conduction.
Nibentan 10-15 mg drip - with resistance to the main drugs, only under conditions of intensive care (!) - has a pronounced proarrhythmic effect, the incidence of severe ventricular arrhythmias is high.

If there are no conditions (impossibility of venous access with reduced blood pressure) for intravenous administration of drugs, use (chew tablets!):
Propranolol (Anaprilin, Obzidan) 20-80mg.
Atenolol (Atenolol) 25-50mg.
Verapamil (Isoptin) 80-120 mg (in the absence of pre-excitation!) in combination with phenazepam (Phenazepam) 1 mg or clonazepam 1 mg.
Or one of the previously effective antiarrhythmics in a double dose of quinidine (Kinidin-durules) 0.2 g, procainamide (Novocainamide) 1.0-1.5 g, disopyramide (Ritmilen) 0.3 g, etacizin (Etacizin) 0.1 g, propafenone (Propanorm) 0.3 g, sotalol (Sotahexal) 80 mg).

In PNT with wide QRS complexes
The tactics are somewhat different, since the ventricular nature of tachycardia cannot be completely excluded, and the possible presence of a preexcitation syndrome imposes certain restrictions. Electrical impulse therapy (EIT) is indicated for hemodynamically significant tachycardias; with satisfactory tolerance of the paroxysm, it is desirable to conduct transesophageal cardiac stimulation (TEPS). Drug relief is carried out with drugs that are effective both in paroxysmal supraventricular tachycardia (PNT) and in ventricular tachycardia: the most commonly used are procainamide (Novocainamide) and / or amiodarone; if they are ineffective, relief is carried out as with ventricular tachycardia (VT). With unspecified wide-complex tachycardia, adenosine (ATP) and ajmaline can also be used (with a very likely supraventricular genesis of tachycardia, they help in the differential diagnosis of supraventricular tachycardia (SVT) and ventricular tachycardia (VT), lidocaine, sotalol.
Do not use cardiac glycosides and verapamil, diltiazem, β-blockers (propranolol, atenolol, nadolol, metoprolol, etc.) because of the possibility of improving conduction along the accessory pathway and the occurrence of flutter or ventricular fibrillation.
In patients with left ventricular dysfunction, only amiodarone, lidocaine, and electrical impulse therapy (EIT) are used to relieve wide complex tachycardia of an unspecified nature.
After testing 1-2 drugs, further attempts at pharmacological relief of an attack should be stopped and switched to PRSS or EIT.

When PNT occurs during pregnancy, class I and III drugs are used.
NB: Multifocal atrial tachycardia requires a special approach to treatment
Table - Averaged data on the effectiveness and order of administration of drugs in paroxysmal PNT

* Efficiency is indicated by signs + (low, less than 10%), ++ low (10-50%), +++ (medium, 50-70%) and ++++ (high, more than 70%).

Maintenance antiarrhythmic therapy in PNT
The decision on the appointment of maintenance therapy depends on the frequency and tolerance of seizures. Tentatively, it can be considered that permanent anti-relapse therapy is indicated for patients who have seizures twice a month or more, and medical assistance is needed to stop them. At the same time, anti-relapse treatment is also recommended for patients with more rare attacks, which are characterized by a protracted course of paroxysms, complicated by cardiovascular or acute left ventricular failure. Conversely, in many cases, patients with frequent but short paroxysms of supraventricular tachycardia, which stop on their own or under the influence of simple vagal maneuvers, do not need constant anti-relapse therapy (such patients often stop taking antiarrhythmic drugs themselves soon after the start of treatment); such tactics are not suitable for patients with pre-excitation syndromes or conduction disorders.
The most adequate method for selecting therapy is transesophageal cardiac stimulation (TEPS) with the identification of the mechanism of paroxysmal supraventricular tachycardias (PNT) and a series of drug tests. In all cases of PNT, especially AV nodal tachycardia, one should strive to establish an accurate electrophysiological diagnosis - to identify additional pathways (DP) of conduction, or an arrhythmogenic zone in PNT without additional pathways (AP).
For long-term anti-relapse treatment of PNT, various antiarrhythmic drugs, as well as cardiac glycosides, are used. The drug and its dose most often have to be selected empirically; while taking into account the efficacy, toxicity and features of the pharmacokinetics of the drug. Often, for the prevention of paroxysms, the same drug is effective as for their relief.
International recommendations of the American and European Heart Associations for the treatment of patients with supraventricular arrhythmias are presented in the table.

It is advisable to start therapy with beta-blockers with a clear stopping effect of paroxysm of vagal tests; if one of them is ineffective, testing the others does not make sense. At the same time, however, it should be remembered that non-selective beta-blockers often turn out to be more effective antiarrhythmics, therefore, in the absence of contraindications and conditions that require the mandatory appointment of highly selective beta-blockers, atenolol (Atenolol) 50-100 mg / day (or propranolol (Anaprilin, Obzidan) 40-160 mg / day in 4 doses). Also used: metoprolol (Vazokardin, Egilok) 50-100 mg/day, betaxolol (Lokren) 10-20 mg/day, bisoprolol (Concor) 5-10 mg/day; in elderly patients, smaller doses may be required. Beta-blockers are widely used in combinations of antiarrhythmic drugs, which allows you to reduce the dose of each of the components included in the combination without reducing the effectiveness of therapy; often combined with class I antiarrhythmics; such combinations are particularly useful when PNT is combined with other arrhythmias. Only opinions about the possibility of combining beta-blockers with verapamil are ambiguous; extreme caution is required.
Verapamil (Isoptin) at a dose of 120-480 mg/day or diltiazem (Diltiazem, Cardil) 180-480 mg/day, preferably in retard form, is prescribed in the absence of WPW syndrome. High doses should not be avoided - the preventive efficacy of drugs is dose-dependent.
In addition, in PNT, the following are effective and consistently used:
Sotalol (Sotalex) 80-320 mg/day (doses of 320 mg/day are rarely achievable; be aware of possible proarrhythmic effects!).
Allapinin (Allapinin) 50-100mg/day.
Propafenone (Propanorm) 450-900 mg/day.
Etatsizin (Etatsizin) 100-150 mg / day (when selecting a dose, electrocardiographic control is necessary).
Disopyramide (Ritmilen) 300-600 mg/day (similar in efficacy to quinidine, but better tolerated by most patients).
Flecainide 200-300mg/day
Quinidine (Kinidin Durules) 400-600 mg/day (be aware of the side effects!).
Azimilide 100-125mg/day.
Amiodarone (Amiodarone, Kordaron) 200-400 mg/day (maintenance dose; saturating - 600-800 mg/day); it is used relatively rarely for the treatment of PNT (be aware of side effects) - if other drugs are ineffective, catheter ablation is usually preferred.

Novocainamide for maintenance therapy is not used because of the very rapid elimination and the risk of developing lupus syndrome. Such antiarrhythmic drugs as aymalin (giluritmal) and the combined antiarrhythmic drug pulsnorma containing it are sometimes used (with proven efficacy for stopping the paroxysm of PNT against the background of WPW) at a dose of 40-60 mg / day; bretilium, mexitil (mexilitin) do not have any advantages over the drugs listed above.
Sometimes it is possible to prevent relapses of supraventricular PNT or reduce the frequency, duration and severity of their course with continuous oral intake of cardiac glycosides (digoxin is most often used). The use of drugs of this group in Wolff-Parkinson-White syndrome is dangerous: the possibility of their appointment is determined in a specialized hospital.
With monotherapy resistant to continuously recurrent paroxysmal supraventricular tachycardia (PNT) (sinus, AV nodal) and undesirability (due to the need to install a permanent pacemaker (EC)) ablation is possible combination therapy verapamil with a class I drug, d, l - sotalol or a beta-blocker (the last 2 combinations require strict control of heart rate (HR), PQ duration, and blood pressure levels).
It is necessary to exclude the use of drugs that cause sinus tachycardia, if paroxysms of PNT become more frequent against their background, as well as limit the intake of alcohol, tea, coffee, and smoking; should be aware of the possibility of the patient using (often hidden) various narcotic substances(amphetamine, ecstasy, etc.).
Maintenance prophylactic therapy for PNT in pregnant women
For the prevention of PNT in pregnant women, it is preferable to prescribe metoprolol, propranolol, sotalol.

Uses of psychotropic drugs
Along with phenazepam 0.5-1mg, clonazepam 0.5-1mg 1-2r/day (on the recommendation of a psychiatrist) and other classes of drugs are often effective in patients with paroxysmal supraventricular tachycardia (PVT), as they help prevent fluctuations in the vegetative status that provoke paroxysms of PVT, as well as facilitate tolerance and relief of an attack.

Other types of treatment: -
Surgical intervention:
Interventional treatment
Surgical treatment is indicated for patients with severe and refractory drug therapy the course of PNT; with WPW syndrome, there are additional indications for surgery.
Two fundamentally different surgical approaches are used:
Destruction (mechanical, electrical, chemical, cryogenic, laser) of additional pathways or foci of heterotopic automatism
Implantation of pacemakers operating in pre-programmed modes (pair stimulation, “exciting” stimulation, etc.).
Recommendations for the treatment of abnormal sinus tachycardia ( Recommendations of the All-Russian Scientific Society of Specialists in Clinical Electrophysiology, Arrhythmology and Cardiac Stimulation, 2011. )

Indication for interventional treatment AWURT.
Recommendations for RFA in AVURT. (Recommendations of the All-Russian Scientific Society of Specialists in Clinical Electrophysiology, Arrhythmology and Cardiac Stimulation, 2011)

Recommendations for radiofrequency catheter ablation of accessory pathways

Recommendations for radiofrequency catheter ablation of atrial tachycardia, flutter and atrial fibrillation

Hospitalization

Frequent or prolonged paroxysms of tachycardia. Hospitalization is emergency and/or planned.

Prevention

Healthy lifestyle.

Information

Sources and literature

1. Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2013
   1. List of references: 1. Bokeria L.A. - Tachyarrhythmias: Diagnosis and surgical treatment - M: Medicine, 1989. 2. Bokeria L.A., Revishvili A.Sh. Catheter ablation of tachyarrhythmias: the current state of the problem and development prospects // Bulletin of Arrhythmology - 1988.- No. 8.- P.70. 3. Revishvili A.Sh. Electrophysiological diagnosis and surgical treatment of supraventricular tachyarrhythmias// Cardiology No. 11-1990, p. 56-59. 4. European Heart Journal 2007 28(5):589-600. 5. Recommendations of the All-Russian Scientific Society of Specialists in Clinical Electrophysiology, Arrhythmology and Cardiac Stimulation, 2011. 6. Crawford MH, Bernstein SJ, Deedwania PC et al. ACC/AHA guidelines for ambulatory electrocardiography: executive summary and recommendations, a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee to Revise the Guidelines for Ambulatory Electrocardiography). Circulation 1999; 100:886-93.

Information

List of protocol developers:
1. Alimbaev S.A. - Candidate of Medical Sciences, Head of the Department of Interventional Cardiology and Radiology of JSC "National Scientific Medical Center".
2. Abdrakhmanov A.S. - Doctor of Medical Sciences, Head of Interventional Arrhythmology, National Scientific Medical Center JSC.
3. Nuralinov O.M. - Cardiologist of the Department of Interventional Arrhythmology of JSC "National Scientific Medical Center".

Reviewers:
Aripov M.A. - Doctor of Medical Sciences, Head of the Department of Interventional Cardiology of JSC "National Scientific Cardiac Surgery Center".

Conditions for revision of the protocol: Once every 5 years, or upon receipt of new data on the diagnosis and treatment of the relevant disease, condition or syndrome.

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According to the localization of impulses, the following types of acceleration of the heart rate are distinguished:

• Ventricular;
• Atrioventricular;
• atrial.

Atrioventricular and atrial types of tachycardia are combined in the category of supraventricular. Classification of the accelerated rhythm along the flow:

1. Acute;
2. Chronic (permanently recurrent);
3. Continuously relapsing.

The recurrent form is formed over the years, leading to heart failure, dilated cardiomyopathy.

Paroxysmal tachycardia: types

Paroxysmal tachycardia is characterized by palpitations with a frequency of 140-200 beats per minute, which occur under the influence of electrical topical impulses. Substitution of normal sinus rhythm against the background of pathology is accompanied by the appearance of paroxysms - contractions with a sudden onset and end. With nosology, the rhythm remains constant, which makes it possible to distinguish paroxysm from extrasystole.

Paroxysmal tachycardia is characterized by a decrease in cardiac performance. Against the background of heart pathology, work with low efficiency, and extraordinary contractions lead to heart failure if they continue for a long time.

Symptoms of paroxysmal tachycardia differ depending on the mechanism of development of the pathology:

1. reciprocal;
2. ectopic;
3. Multifocal.

The reciprocal type (re-entry) is characterized by the re-entry of the impulse into the heart muscle, the appearance of a circular excitatory wave in the myocardium. The second mechanism of the formation of the disease is the development of an ectopic focus of automatism and depolarization trigger activity. Regardless of the mechanism of development of paroxysm, a focus of depolarization trigger activity occurs. Such a state is always preceded by a wave of extrasystole (the appearance of extraordinary heart contractions).

Morphological changes in the body with paroxysmal tachycardia

The supraventricular type of the disease is characterized by an increase in the activity of the sympathetic nervous system in combination with morphological changes in the myocardium:

• Dystrophic;
• Inflammatory;
• Sclerotic.

If the pathology exists for a long time, the above changes lead to irreversible consequences.

Ventricular paroxysmal tachycardia is characterized by the occurrence of an area of ​​ectopic excitation in the myocardial conduction system, Purkinje fibers, and His bundle. The disease often occurs in elderly patients who have had a myocardial infarction, with heart defects or hypertension. A prolonged paroxysm leads to a decrease in pressure, the development of fainting and weakness. Paroxysmal tachycardia is worse tolerated by patients with cardiomyopathy.

With a ventricular form of pathology, the prognosis is less favorable than with atrial. In practice, doctors with nosology encounter serious complications in the form of atrial fibrillation, atrial fibrillation. Long-term paroxysm leads to pulmonary edema, cardiogenic shock. A decrease in cardiac output leads to heart failure and irreversible changes in the myocardium.

The main symptoms of paroxysmal tachycardia:

1. Attacks of increased heart rate over 120 beats per minute;
2. Dyspnea;
3. Feeling of pressure in the chest;
4. Polyuria after cessation of attack.

Symptoms of nosology arise and end abruptly. According to clinical features, 2 types of increased heart rate are distinguished: extrasystolic, essential. Pathology is distinguished by the location of impulses leading to an increase in rhythm.

Essential paroxysmal tachycardia is accompanied by an unexpected attack. At the initial and final stages of nosology, extrasystoles are not traced.

Between paroxysms of the extrasystolic form, an increase in the rhythm can be traced and extrasystoles (extrasystolie a paroxysmes tachycardiques) may appear. A feature of the disease is a rare frequency of extraordinary contractions with an altered QRS complex.

Patients with pathology present different complaints:

• minor discomfort;
• Compression behind the sternum;
• congestive changes in the liver;
• Dizziness;
• Noise in the head;
• Feeling of constriction of the heart.

After the attack stops, a person develops polyuria (copious urine output). With a prolonged attack, the patient may experience symptoms of vegetative-vascular dystonia.

Paroxysmal tachycardia is difficult to tolerate. With it, the frequency of strokes can reach 180 per minute. Nosology can cause ventricular fibrillation.

Description of the disease

Supraventricular paroxysmal tachycardia is a violation of the rhythm of heart contractions, in which the atria, sinus and atrioventricular nodes become the source of excitation. The formation of reciprocal forms of nosology occurs due to the activation of additional sources of rhythm.

Types of supraventricular tachycardia:

• Spontaneous;
• Nodal reciprocal;
• Focal;
• Polytopic.

The spontaneous form is accompanied by an increase in heart rate due to emotional and physical stress. There is a form with prolonged use of certain drugs. The main cause of the disease is considered to be an increase in the automatism of the sinus node. Symptoms of the disease manifest differently in patients. In some people, it is asymptomatic. The remaining group of patients presents the doctor with the following symptoms:

• Chest pain;
• Heartbeat;
• Lack of air;
• dizziness;
• Fainting states.

When conducting examinations with spontaneous tachycardia, with the exception of a rapid rhythm (more than 100 beats per minute), no other clinical signs of the disease can be traced.

The nodular reciprocal form has a paroxysmal course. With her, the rhythm of heart contractions is 80-120 beats per minute. Its causes are considered diseases of the cardiovascular system. This type of arrhythmias occurs with the same frequency in men and women, is detected in the elderly, and is occasionally observed in children.

Paroxysm of reciprocal tachycardia occurs in the presence of heart disease.

The classic course of the disease is not characterized by severe symptoms. Palpitations, dizziness, shortness of breath, and other respiratory disorders are formed in a narrow circle of patients. Interictal period accompanied only by bradycardia (decreased heart rate).

The focal form is provoked by the focus of myocardial excitation. The site of increased activity is localized in the atria. The frequent location of the focus is the pulmonary veins. Pathology traces in people with the following diseases:

• Cardiomyopathy - a violation of the contractile function of the heart muscle;
• Cardiopulmonary failure;
• heart attack;
• Rheumocarditis.

The paroxysm of tachycardia is provoked by hypoxia, hypokalemia, an overdose of cardiac drugs (eufillin, digitalis), atrial hyperextension.

A decrease in blood pressure is observed with a high ventricular rate. Swelling of the lower leg, shortness of breath, intoxication with cardiac glycosides leads to loss of appetite.

The polytopic form of the disease is accompanied by the appearance of P waves on the cardiogram, which change the rhythm of heart contractions. The disease is formed during hypoxia, electrolyte imbalance.

Glycoside intoxication contributes to paroxysmal tachycardia. Arrhythmia occurs with increased automatism of the sinus node. The average age of patients is 32 years. The female gender is more prone to nosology.

Symptoms of the polytopic form:

• Sudden onset of an attack;
• Heartbeat;
• Cold extremities;
• increased sweating;
• Heaviness in the head.

Complications of pathology from the side gastrointestinal tract: intestinal heaviness, diarrhea, anxiety, agitation, constipation. Intoxication syndrome leads to damage to the central nervous system: cerebral ischemia, loss of consciousness. The lethal outcome is observed from cardiogenic shock and pulmonary edema.

Paroxysmal tachycardia: treatment

Supraventricular paroxysms require emergency hospitalization of the patient in the formation of cardiopulmonary insufficiency. Scheduled entry in cardiology department carried out with frequent paroxysmal attacks (more than 2 per month). Relief of paroxysm is carried out by vagal techniques (test of Ashner, Valsava, Cermak-Goering):

1. With the mouth closed, the nasal slit make a strong exhalation;
2. Pressure on the inside of the eyeball;
3. Compression of the carotid sinus of the carotid artery;
4. Calling the gag reflex by pressing the fingers on the root of the tongue.

Vagal maneuvers eliminate supraventricular paroxysms. Other forms are stopped by medications:

• Kordaron;
• Isoptin;
• Etmozin;
• Ritmodan;
• Quinidine;
• Aymalin;
• propranolol;
• Novocainamide.

Relief of an attack is carried out under the control of a cardiologist!

Palpitations, high blood pressure, low blood pressure are typical symptoms of supraventricular tachycardia.

An electrical impulse from the atrioventricular node physiologically excites a significant part of the atrial and ventricular myocardium.

The disease has a paroxysmal course. It occurs more often in children. It is provoked by a violation of the conduction of the myocardium. Tachycardia is provoked by a violation of the passage of an electrical impulse through the atria. The clinical picture is accompanied by an increase in the rhythm over 140 beats per minute.

The right atrium contains the sinoatrial node, which regulates the rhythm of heart contractions. At pathological change this area increases the frequency of contractions.

Supraventricular tachycardia is a collective term that includes a number of atrioventricular and atrial conditions:

1. Wolff-Parkinson-White Syndrome (WPW);
2. Blockade of the legs of Gis;
3. Difficulties in conduction along the atrioventricular part of the myocardium;
4. Narrowness of the QRS complex.

Symptoms of supraventricular tachycardia:

• chest pain;
• Dizziness;
• Increased heart rate.

Pathology is dangerous with the occurrence of heart failure. With it, prolonged attacks are observed, after which a decrease in blood pressure is observed.

For reliable diagnosis of nosology, electrocardiography (ECG) is used. Additional studies can reveal the pathology of the myocardial conduction system.

With a mild course of pathology, it is enough to stimulate nervus vagus. For these purposes, the vagal technique is used:

1. Massage the carotid artery in the bifurcation area;
2. Exhale with your mouth and nose closed.

Complications of accelerated heart rate

The danger of pathology is the formation of life-threatening conditions:

• Heart failure;
• Pulmonary edema;
• cardiomyopathy;
• Hypertrophic cardiomyopathy;
• Thickening of the myocardium.

Dilated cardiomyopathy leads to the death of a person after 5-7 years. Drug therapy helps to prolong a person's life. Women with pathology cannot become pregnant, as the bearing of a child creates a strong load on the heart.

The hypertrophic form leads to thickening of the muscle. The expansion of the cavities is not observed, since the compacted layer of the myocardium limits the stretching.

Restrictive cardiomyopathy is accompanied by a pathology of the contractile function of the heart muscle. Muscle fibers in pathology are stretched, which disrupts the blood supply.

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Classification of paroxysmal tachycardia

At the place of localization of pathological impulses, atrial, atrioventricular (atrioventricular) and ventricular forms of paroxysmal tachycardia are distinguished. Atrial and atrioventricular paroxysmal tachycardias are combined into a supraventricular (supraventricular) form.

According to the nature of the course, there are acute (paroxysmal), constantly recurrent (chronic) and continuously recurrent forms of paroxysmal tachycardia. The course of a continuously relapsing form can last for years, causing arrhythmogenic dilated cardiomyopathy and circulatory failure. According to the development mechanism, reciprocal (associated with the re-entry mechanism in the sinus node), ectopic (or focal), multifocal (or multifocal) forms of supraventricular paroxysmal tachycardia are distinguished.

The mechanism of development of paroxysmal tachycardia in most cases is based on the re-entry of the impulse and the circular circulation of excitation (reciprocal re-entry mechanism). Less commonly, paroxysm of tachycardia develops as a result of the presence of an ectopic focus of abnormal automatism or a focus of post-depolarization trigger activity. Regardless of the mechanism of occurrence of paroxysmal tachycardia, the development of extrasystole always precedes.

Causes of paroxysmal tachycardia

According to etiological factors, paroxysmal tachycardia is similar to extrasystole, while the supraventricular form is usually caused by an increase in the activation of the sympathetic part of the nervous system, and the ventricular form is usually caused by inflammatory, necrotic, dystrophic or sclerotic lesions of the heart muscle.

In the ventricular form of paroxysmal tachycardia, the focus of ectopic excitation is located in the ventricular parts of the conduction system - the bundle of His, its legs, and Purkinje fibers. The development of ventricular tachycardia is more often observed in elderly men with coronary artery disease, myocardial infarction, myocarditis, hypertension, heart disease.

An important prerequisite for the development of paroxysmal tachycardia is the presence of additional pathways for conducting an impulse in the myocardium of a congenital nature (Kent's bundle between the ventricles and the atria, bypassing the atrioventricular node; Maheim's fibers between the ventricles and the atrioventricular node) or resulting from myocardial damage (myocarditis, infarction, cardiomyopathy). Additional pathways for conducting an impulse cause pathological circulation of excitation through the myocardium.

In some cases, the so-called longitudinal dissociation develops in the atrioventricular node, leading to uncoordinated functioning of the fibers of the atrioventricular junction. With the phenomenon of longitudinal dissociation, part of the fibers of the conducting system functions without deviations, while the other, on the contrary, conducts excitation in the opposite (retrograde) direction and serves as the basis for the circular circulation of impulses from the atria to the ventricles and then along the retrograde fibers back to the atria.

In childhood and adolescence, idiopathic (essential) paroxysmal tachycardia sometimes occurs, the cause of which cannot be reliably established. The basis of neurogenic forms of paroxysmal tachycardia is the influence of psychoemotional factors and increased sympathoadrenal activity on the development of ectopic paroxysms.

Symptoms of paroxysmal tachycardia

The paroxysm of tachycardia always has a sudden, distinct beginning and the same end, while its duration can vary from several days to several seconds.

The patient feels the beginning of paroxysm as a push in the region of the heart, turning into an increased heartbeat. The heart rate during paroxysm reaches 140-220 or more per minute with the correct rhythm maintained. An attack of paroxysmal tachycardia may be accompanied by dizziness, noise in the head, a feeling of constriction of the heart. Less often, transient focal neurological symptoms are noted - aphasia, hemiparesis. The course of paroxysm of supraventricular tachycardia can occur with symptoms of autonomic dysfunction: sweating, nausea, flatulence, mild subfebrile condition. At the end of the attack, polyuria is noted for several hours with the release of a large amount of light urine of low density (1.001-1.003).

The protracted course of paroxysmal tachycardia can cause a drop in blood pressure, the development of weakness and fainting. Tolerability of paroxysmal tachycardia is worse in patients with cardiopathology. Ventricular tachycardia usually develops against the background of heart disease and has a more serious prognosis.

Complications of paroxysmal tachycardia

With a ventricular form of paroxysmal tachycardia with a rhythm frequency of more than 180 beats. per minute, ventricular fibrillation may develop. Prolonged paroxysm can lead to severe complications: acute heart failure (cardiogenic shock and pulmonary edema). A decrease in cardiac output during paroxysmal tachycardia causes a decrease coronary blood supply and ischemia of the heart muscle (angina pectoris or myocardial infarction). The course of paroxysmal tachycardia leads to the progression of chronic heart failure.

Diagnosis of paroxysmal tachycardia

Paroxysmal tachycardia can be diagnosed by the typicality of an attack with a sudden onset and end, as well as data from a study of heart rate. Supraventricular and ventricular forms of tachycardia differ in the degree of increased rhythm. With a ventricular form of tachycardia, the heart rate usually does not exceed 180 beats. per minute, and tests with excitation of the vagus nerve give negative results, while with supraventricular tachycardia, the heart rate reaches 220-250 beats. per minute, and the paroxysm is stopped with the help of a vagal maneuver.

When registering an ECG during an attack, characteristic changes in the shape and polarity of the P wave, as well as its location relative to the ventricular QRS complex, are determined, which make it possible to distinguish the form of paroxysmal tachycardia. For the atrial form, the location of the P wave (positive or negative) in front of the QRS complex is typical. With a paroxysm emanating from the atrioventricular junction, a negative P wave is recorded, located behind the QRS complex or merging with it. The ventricular form is characterized by deformation and expansion of the QRS complex, resembling ventricular extrasystoles; a normal, unchanged P wave can be recorded.

If the paroxysm of tachycardia cannot be fixed with electrocardiography, they resort to daily ECG monitoring, which records short episodes of paroxysmal tachycardia (from 3 to 5 ventricular complexes), which are not subjectively felt by patients. In some cases, with paroxysmal tachycardia, an endocardial electrocardiogram is recorded by intracardiac insertion of electrodes. To exclude organic pathology, ultrasound of the heart, MRI or MSCT of the heart are performed.

Treatment of paroxysmal tachycardia

The question of the tactics of treating patients with paroxysmal tachycardia is decided taking into account the form of arrhythmia (atrial, atrioventricular, ventricular), its etiology, the frequency and duration of attacks, the presence or absence of complications during paroxysms (cardiac or cardiovascular failure).

Most cases of ventricular paroxysmal tachycardia require emergency hospitalization. The exception is idiopathic variants with a benign course and the possibility of rapid relief by administering a specific antiarrhythmic drug. With a paroxysm of supraventricular tachycardia, patients are hospitalized in the cardiology department in case of acute cardiac or cardiovascular failure.

Planned hospitalization of patients with paroxysmal tachycardia is carried out with frequent, > 2 times a month, attacks of tachycardia for an in-depth examination, determination of therapeutic tactics and indications for surgical treatment.

The occurrence of an attack of paroxysmal tachycardia requires the provision of urgent measures on the spot, and in case of primary paroxysm or concomitant cardiac pathology, a simultaneous call to an ambulance cardiological service is necessary.

To stop the paroxysm of tachycardia, they resort to vagal maneuvers - techniques that have a mechanical effect on the vagus nerve. Vagal maneuvers include straining; Valsalva test (an attempt to exhale vigorously with the nasal fissure and oral cavity closed); Ashner's test (uniform and moderate pressure on the upper inner corner eyeball); Cermak-Goering test (pressure on the area of ​​one or both carotid sinuses in the area of ​​the carotid artery); an attempt to induce a gag reflex by irritating the root of the tongue; wiping with cold water, etc. With the help of vagal maneuvers, it is possible to stop only attacks of supraventricular paroxysms of tachycardia, but not in all cases. Therefore, the main type of assistance with developed paroxysmal tachycardia is the introduction of antiarrhythmic drugs.

As an emergency, intravenous administration of universal antiarrhythmics is indicated, effective for any form of paroxysm: novocainamide, propranolola (obzidan), aymalin (giluritmal), quinidine, rhythmodan (disopyramide, rhythmilek), ethmozine, isoptin, cordarone. With prolonged paroxysms of tachycardia that are not stopped by drugs, they resort to electrical impulse therapy.

In the future, patients with paroxysmal tachycardia are subject to outpatient monitoring by a cardiologist, who determines the amount and schedule of antiarrhythmic therapy. The appointment of anti-relapse antiarrhythmic treatment of tachycardia is determined by the frequency and tolerance of attacks. Carrying out continuous anti-relapse therapy is indicated for patients with tachycardia paroxysms that occur 2 or more times a month and require medical assistance for their cupping; with more rare, but prolonged paroxysms, complicated by the development of acute left ventricular or cardiovascular failure. In patients with frequent, short episodes of supraventricular tachycardia that resolve spontaneously or with vagal maneuvers, indications for anti-relapse therapy are questionable.

Long-term anti-relapse therapy of paroxysmal tachycardia is carried out with antiarrhythmic drugs (quinidine bisulfate, disopyramide, moracizin, etacizin, amiodarone, verapamil, etc.), as well as cardiac glycosides (digoxin, lanatoside). The selection of the drug and dosage is carried out under electrocardiographic control and control of the patient's well-being.

The use of β-blockers for the treatment of paroxysmal tachycardia can reduce the likelihood of the transition of the ventricular form to ventricular fibrillation. The most effective use of β-blockers in conjunction with antiarrhythmic drugs, which allows you to reduce the dose of each of the drugs without compromising the effectiveness of the therapy. Prevention of recurrence of supraventricular paroxysms of tachycardia, reduction in the frequency, duration and severity of their course is achieved by constant oral intake of cardiac glycosides.

Surgical treatment is resorted to with a particularly severe course of paroxysmal tachycardia and the ineffectiveness of anti-relapse therapy. As a surgical aid for paroxysms of tachycardia, destruction (mechanical, electrical, laser, chemical, cryogenic) of additional pathways for impulse conduction or ectopic foci of automatism, radiofrequency ablation (RFA of the heart), implantation of pacemakers with programmed modes of paired and “exciting” stimulation, or implantation of electrical defibrillators.

Prognosis for paroxysmal tachycardia

Prognostic criteria for paroxysmal tachycardia are its form, etiology, duration of attacks, the presence or absence of complications, the state of myocardial contractility (since with severe damage to the heart muscle, there is a high risk of developing acute cardiovascular or heart failure, ventricular fibrillation).

The most favorable course is the essential supraventricular form of paroxysmal tachycardia: most patients do not lose their ability to work for many years, cases of complete spontaneous recovery are rarely observed. The course of supraventricular tachycardia caused by myocardial diseases is largely determined by the rate of development and the effectiveness of therapy for the underlying disease.

The worst prognosis is observed in the ventricular form of paroxysmal tachycardia, which develops against the background of myocardial pathology (acute infarction, extensive transient ischemia, recurrent myocarditis, primary cardiomyopathies, severe myocardial dystrophy due to heart defects). Myocardial damage contributes to the transformation of tachycardia paroxysms into ventricular fibrillation.

In the absence of complications, the survival of patients with ventricular tachycardia is years and even decades. A lethal outcome in the ventricular form of paroxysmal tachycardia, as a rule, occurs in patients with heart defects, as well as in patients who have previously undergone sudden clinical death and resuscitation. Improves the course of paroxysmal tachycardia constant anti-relapse therapy and surgical correction of the rhythm.

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Classification

Supraventricular tachycardia, depending on the source of the rhythm, is divided into atrial and atrioventricular (atrioventricular) forms. In the second case, regular nerve impulses that propagate throughout the heart are generated in the atrioventricular node.

According to the international classification, tachycardias are distinguished with a narrow QRS complex and a wide QRS. Supraventricular forms are divided into 2 types according to the same principle.

A narrow QRS complex on the ECG is formed during the normal passage of a nerve impulse from the atrium to the ventricles through the atrioventricular (AV) node. All wide QRS tachycardias imply the occurrence and functioning of an abnormal atrioventricular conduction focus. The nerve signal travels bypassing the AV junction. Due to the extended QRS complex, such arrhythmias on the electrocardiogram are quite difficult to distinguish from the ventricular rhythm with an increased heart rate (HR), so the arrest of the attack is carried out in exactly the same way as with ventricular tachycardia.

The prevalence of pathology

According to world observations, supraventricular tachycardia occurs in 0.2-0.3% of the population. Women are twice as likely to suffer from this pathology.

In 80% of cases, paroxysms occur in people older than 60-65 years. In 20 out of a hundred patients, atrial forms are diagnosed. The remaining 80% suffer from atrioventricular paroxysmal tachycardia.

Causes of supraventricular tachycardia

Leading etiological factors pathologies are organic damage to the myocardium. These include various sclerotic, inflammatory and dystrophic tissue changes. These conditions often occur in chronic coronary heart disease (CHD), some defects and other cardiopathies.

The development of supraventricular tachycardia is possible in the presence of abnormal pathways for conducting a nerve signal to the ventricles from the atria (for example, WPW syndrome).

In all likelihood, despite the denials of many authors, there are neurogenic forms of paroxysmal supraventricular tachycardia. This form of rhythm disturbance can occur with increased activation of the sympathetic nervous system during excessive psycho-emotional stress.

Mechanical effects on the heart muscle in some cases are also responsible for the occurrence of tachyarrhythmias. This occurs when there are adhesions or additional chords in the cavities of the heart.

At a young age, it is often impossible to determine the cause of supraventricular paroxysms. This is probably due to changes in the heart muscle that have not been studied or not determined by instrumental research methods. However, such cases are regarded as idiopathic (essential) tachycardias.

AT rare cases the main cause of supraventricular tachycardia is thyrotoxicosis (the body's response to elevated levels of thyroid hormones). Because this disease can create some barriers to antiarrhythmic treatment, hormone testing should be performed in any case.

The mechanism of occurrence of tachycardia

The basis of the pathogenesis of supraventricular tachycardia is a change in the structural elements of the myocardium and activation of trigger factors. The latter include electrolyte disturbances, changes in myocardial extensibility, ischemia, and the effects of certain medicines.

Leading mechanisms for the development of paroxysmal supraventricular tachycardia:

1. Increasing the automatism of individual cells located along the entire path of the conduction system of the heart with a trigger mechanism. This type of pathogenesis is rare.
2. re-entry mechanism. In this case, there is a circular propagation of the excitation wave with re-entry (the main mechanism for the development of supraventricular tachycardia).

The two mechanisms described above can exist in violation of the electrical homogeneity (homogeneity) of the muscle cells of the heart and the cells of the conducting system. In the vast majority of cases, the interatrial Bachmann bundle and elements of the AV node contribute to the occurrence of abnormal nerve impulse conduction. The heterogeneity of the cells described above is genetically determined and is explained by the difference in the operation of ion channels.

Clinical manifestations and possible complications

The subjective sensations of a person with supraventricular tachycardia are very diverse and depend on the severity of the disease. With a heart rate of up to 130-140 beats per minute and a short duration of an attack, patients may not feel any disturbance at all and be unaware of the paroxysm. If the heart rate reaches 180-200 beats per minute, patients mostly complain of nausea, dizziness or general weakness. Unlike sinus tachycardia, with this pathology autonomic symptoms in the form of chills or sweating are less pronounced.

All clinical manifestations directly depend on the type of supraventricular tachycardia, the body's response to it and concomitant diseases (especially heart disease). However, common symptom almost all paroxysmal supraventricular tachycardias is a feeling of rapid or increased heartbeat.

Possible clinical manifestations in patients with damage to the cardiovascular system:

• fainting (in about 15% of cases);
• pain in the region of the heart (more often in patients with coronary artery disease);
• shortness of breath and acute insufficiency blood circulation with all sorts of complications;
• cardiovascular insufficiency (with a prolonged course of an attack);
• cardiogenic shock (in case of paroxysm on the background of myocardial infarction or congestive cardiomyopathy).

Paroxysmal supraventricular tachycardia can manifest itself in completely different ways, even in people of the same age, gender and state of health of the body. In one patient, short-term attacks occur monthly/yearly. Another patient can only endure a long paroxysmal attack without harm to health only once in his life. There are many intermediate variants of the disease relative to the above examples.

Diagnostics

A person should be suspected of having such a disease, in whom, for no particular reason, either a feeling of rapid heartbeat, or bouts of dizziness or shortness of breath, abruptly begins and just as abruptly ends. To confirm the diagnosis, it is enough to study the patient's complaints, listen to the work of the heart and take an ECG.

When listening to the work of the heart with a conventional phonendoscope, you can determine a rhythmic rapid heartbeat. With a heart rate exceeding 150 beats per minute, the option of sinus tachycardia is immediately excluded. If the heart rate is more than 200 beats, then ventricular tachycardia is also unlikely. But such data is not enough, because the above heart rate range may include both atrial flutter and correct form atrial fibrillation.

Indirect signs of supraventricular tachycardia are:

• frequent weak pulse that cannot be accurately counted;
• lowering blood pressure;
• labored breathing.

The basis for the diagnosis of all paroxysmal supraventricular tachycardias is an ECG study and Holter monitoring. Sometimes you have to resort to methods such as PRSS (transesophageal cardiac stimulation) and stress ECG tests. Less often, if absolutely necessary, an EFI (intracardiac electrophysiological study) is performed.

The main signs of supraventricular tachycardia on the ECG are an increase in heart rate above normal with the absence of P waves. Sometimes the waves can be biphasic or deformed, however, due to frequent ventricular QRS complexes, they cannot be detected.

There are 3 main pathologies with which it is important to make a differential diagnosis of classical supraventricular arrhythmia:

• Sick sinus syndrome (SSS). In case of not detecting an existing disease, relief and further treatment paroxysmal tachycardia can be dangerous.
• Ventricular tachycardia (in which the ventricular complexes are very similar to those in QRS-extended supraventricular tachycardia).
• Syndromes of preexcitation of the ventricles. (including WPW syndrome).

Treatment of supraventricular tachycardia

Treatment depends entirely on the form of tachycardia, the duration of attacks, their frequency, complications of the disease and comorbidities. Supraventricular paroxysm should be stopped on the spot. This requires an ambulance call. In the absence of effect or the development of complications in the form of cardiovascular insufficiency or acute violation of cardiac circulation, urgent hospitalization is indicated.

Direction to hospital treatment routinely receive patients with frequently recurrent paroxysms. Such patients undergo an in-depth examination and decide on surgical treatment.

Relief of paroxysmal supraventricular tachycardia

With this variant of tachycardia, vagal tests are quite effective:

• Valsalva test - straining while holding your breath (the most effective);
• Ashner's test - pressure on the eyeballs for a short period of time, not exceeding 5-10 seconds;
• massage of the carotid sinus (the area of ​​​​the carotid artery on the neck);
• lowering the face into cold water;
• deep breathing;
• squatting.

These methods of stopping an attack should be used with caution, because. in case of a stroke, severe heart failure, glaucoma or SSS, these manipulations can be harmful to health.

Often the above actions are ineffective, so you have to resort to restoring a normal heartbeat with the help of drugs, electrical impulse therapy (EIT) or transesophageal stimulation of the heart. The latter option is used for intolerance to antiarrhythmic drugs or for tachycardia with a pacemaker from the AV junction.

For the correct choice of method of treatment, it is desirable to determine the specific form of supraventricular tachycardia. Due to the fact that in practice there is often emergency in stopping the attack "right now" and there is no time for differential diagnosis, the rhythm is restored according to the algorithms developed by the Ministry of Health.

Cardiac glycosides and antiarrhythmic drugs are used to prevent recurrence of paroxysmal supraventricular tachycardia. The dosage is selected individually. Often, the same medicinal substance is used as an anti-relapse drug, which successfully stopped the paroxysm.

The mainstay of treatment is beta-blockers. These include: anaprilin, metoprolol, bisoprolol, atenolol. For the best effect and in order to reduce the dosage, these medicinal substances are used in conjunction with antiarrhythmic drugs. The exception is verapamil(this drug is highly effective for stopping paroxysms, however, its unreasonable combination with the above drugs is extremely dangerous).

Caution should also be taken in the treatment of tachycardia in the presence of WPW syndrome. In this case, in most cases, it is also forbidden to use verapamil, and cardiac glycosides should be used with extreme caution.

In addition, the effectiveness of other antiarrhythmic drugs has been proven, which are prescribed sequentially depending on the severity and stopping of paroxysms:

• sotalol,
• propafenone,
• etatsizin,
• disopyramide,
• quinidine,
• amiodarone,

In parallel with taking anti-relapse drugs, the use of any medicinal substances capable of causing tachycardia. It is also undesirable to drink strong tea, coffee, alcohol.

In severe cases and with frequent relapses, surgical treatment is indicated. There are two approaches:

1. Destruction of additional conductive paths by chemical, electrical, laser or other means.
2. Implantation of pacemakers or mini defibrillators.

Forecast

With essential paroxysmal supraventricular tachycardia, the prognosis is often favorable, although a complete cure is quite rare. Supraventricular tachycardias that occur against the background of cardiac pathology are more dangerous for the body. With proper treatment, the likelihood of its effectiveness is high. Complete cure also impossible.

Prevention

There is no specific warning for the occurrence of supraventricular tachycardia. Primary prevention is the prevention of the underlying disease that causes paroxysms. Secondary prevention can be attributed to adequate therapy of the pathology that provokes attacks of supraventricular tachycardia.

Thus, supraventricular tachycardia in most cases is an emergency condition that requires emergency help medical specialists.

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What happens when you get sick?

There are two main mechanisms for the development of paroxysmal supraventricular tachycardia.

With one of them, a normal, physiological, source of impulses ceases to control heart contractions. They begin to be carried out under the influence of signals coming from an abnormal focus of automatism. This focus can be located in the atrioventricular or atrial zone, i.e. located above the ventricles of the heart, which gave this type of disease the name paroxysmal supraventricular tachycardia, or supraventricular.

The second mechanism for the occurrence of pathology is the circulation of an impulse in a vicious circle, which maintains an abnormally high heart rate (the so-called “re-entry” of excitation). The occurrence of such a state becomes possible with the appearance of "bypass" paths for the excitation pulse.

Causes of tachycardia attacks

The disease has a multifactorial nature. The main causes of the appearance of pathology include:

• An increase in the tone of the sympathetic part of the nervous system, which can be caused by multiple stresses, leading to a constantly elevated blood concentration of adrenaline and norepinephrine.
• The presence of constant reflex irritation emanating from pathologically altered organs. This can be observed in diseases of the spine (osteochondrosis, spondylarthrosis), respiratory and digestive organs.
• Dystrophic changes in the heart muscle (atherosclerotic and post-infarction cardiosclerosis, myocarditis, heart defects, toxic changes in diffuse goiter, severe infections).
• Toxic damage to the heart of a medicinal nature (digitalis preparations, quinidine, etc.).
• Chronic and acute intoxication with alcohol, drugs, industrial chemicals.
• The presence of additional (abnormal) ways of conducting a cardiac impulse. They can be congenital and acquired. In the latter case, the cause may be cardiomyopathy, myocarditis.

Symptoms and clinic of paroxysmal tachycardia

An attack (paroxysm) of supraventricular tachycardia is characterized by a clearly defined beginning and the same sudden end. The patient notes a push in the region of the heart, which immediately turns into a rapid heartbeat.

The frequency of contractions of the heart muscle during an attack of paroxysmal tachycardia exceeds 100 beats per minute and can reach 200 or more (up to 300 in children) while maintaining the correct rhythm. The duration of an episode can vary from seconds to several days.

Immediately during an episode of paroxysmal tachycardia, the condition may remain satisfactory, in some cases there is a feeling of suffocation, darkening of the eyes, trembling of the fingers. Occasionally, neurological disorders are possible - speech disorders, hemiparesis (a temporary disorder of sensitivity and active movements on one of the halves of the body).

Sometimes there may be phenomena that testify in favor of vegetative disorders - increased intestinal peristalsis, sweating. At the end of the attack, urination may occur.

A prolonged attack creates a danger to life, since a large number of contractions of the heart muscle is not functionally effective. Cardiac output (the volume of blood pumped through the vessels) drops sharply, resulting in progressive heart failure. It, in turn, leads to oxygen starvation internal organs. The most significant is hypoxia of the brain and the heart muscle itself - fainting and myocardial infarction are possible, as well as thromboembolic complications.

Diagnosis of the disease

A preliminary diagnosis of "supraventricular tachycardia" can be made after questioning the patient on the basis of the presence of characteristic seizures with a clear beginning and end.

With auscultation of the heart and control of the pulse produced during the attack of paroxysmal tachycardia, the preservation of the rhythm with an increase in the number of contractions is determined, the heart sounds remain clear.

Systolic blood pressure is reduced, diastolic decreases or remains within the normal range.

On the ECG performed at the time of paroxysmal tachycardia, there are normal unchanged ventricular complexes, the atrial P wave may be normal, often it merges with the ventricular complex. The rhythm is correct, sharply accelerated. Perhaps the appearance of signs of atrioventricular conduction, up to a complete blockade.

To additional methods Investigations include ultrasound and tomography of the heart.

What to do during an attack

Treatment for paroxysmal supraventricular tachycardia in each case is individual and is determined by the severity of the patient's condition, the frequency of attacks and their duration, the presence or absence of complications (heart failure).

At the pre-medical stage, it is possible to use simple methods of stimulating the vagus nerve, which acts on heart contractions in a slower way. To do this, you can try to induce vomiting movements with your fingers inserted into the throat or press on the eyeballs, start massaging the abdominal press in the projection of the diaphragm.

Often, with an attack of paroxysmal tachycardia, stimulation of the carotid sinus is effective. This formation is located at the base of the sternocleidomastoid muscle, which is located on the anterolateral surface of the neck and is clearly visible when the head is turned sideways. Stimulation is carried out by strongly squeezing the sinus area with your fingers for a few seconds alternately on each side. In old age, this method of assistance should be performed with great care, since it can cause a violation of cerebral blood supply.

Sometimes an attack of tachycardia can be interrupted by holding the breath, straining, turning the head, washing with ice water, swallowing solid food. If the attack has been successfully controlled, the patient must be laid down and provided with physical and emotional rest.

Of the drugs, the introduction of adrenoblockers (propranolol), verapamil, novocainamide, cardiac glycosides (digoxin) is indicated, with a pronounced decrease in pressure - mezaton.

With increasing symptoms of heart failure (feeling of suffocation, cyanosis of the skin of the face) or suspected myocardial infarction (severe pain in the heart), mandatory hospitalization is required, while treatment is carried out in the intensive care unit.

Medical assistance

Emergency care is carried out in a hospital or by doctors of "Ambulance":

• Antiarrhythmic drugs (novocainamide intravenously in glucose solution).
• Calcium antagonists (verapamil intravenously).
• Adenosine triphosphate (ATP) intravenous bolus. The drug has the ability to interrupt the pathological circulation of re-excitation.
• With a sharp decrease in pressure, electrical impulse therapy is performed.

Outside of an attack, glycosides, adrenergic blockers, verapamil, amiodarone, aymalin are indicated.

Surgery

Before the operation, several electrocardiograms are taken from electrodes inserted directly into the myocardium in order to accurately establish the localization of sources of pathological impulses.

Destruction of anomalous formations can be performed using high or low temperatures, laser radiation, mechanical vibrations or electric current.

The installation of a pacemaker or defibrillator is aimed at automatically turning on the device after the onset of a tachycardia attack and stopping it by creating a powerful source of the correct rhythm.

Disease prevention

Prevention of the occurrence of paroxysms of supraventricular tachycardia is the timely detection and treatment of the underlying disease - the cause of the pathology (cardiomyopathy, heart disease, endocrine diseases).

Persons who are prone to tachycardia attacks should avoid alcohol and drugs. Contact with industrial and household toxic substances must be eliminated.

Disorders in the regulation of the frequency of contractions of the heart muscle, as well as problems with the conduction of electrical impulses, often lead to the development of supraventricular tachycardia, which is also called supraventricular.

Supraventricular tachycardia - ICD code 10 I47.1 - is a genetic disease and is often diagnosed in childhood.

The pathology under consideration is divided into and, atrioventricular nodal disorder.

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The disease can be deadly or, conversely, indicate a benign deviation. But according to experts, tachycardia rarely causes serious harm to health.

The reasons

The development of supraventricular tachycardia is greatly influenced by the state of the human nervous system. So, in adolescence, the patient develops deviations from the norm only through the occurrence of a stressful situation, some kind of excitement, an emotional event.

At a more mature age, pathology often develops due to identified neurasthenia, contusion, menopausal changes and other factors. Also, the development of tachycardia is affected by disorders in the work of internal organs - the kidneys, organs of the gastrointestinal tract, lungs, genitals and even the spine.

The development of pathology is influenced by the intake of certain drugs - Quinidine, Novocainomid and others. An overdose of cardiac glycosides is also isolated here, which often leads to the death of the patient. The reason for such cases is a sharp decrease in the level of potassium in the human body.

Supraventricular tachycardia can act as a complication of hypertension, a long-term infectious disease. Often, during a heart operation, it becomes necessary to apply electrical impulses - this can also provoke tachycardia.

Symptoms

Symptoms of supraventricular tachycardia appear sharply - this is due to an increase in contractions - 150-250 contractions per minute. The more contractions, the more pronounced the symptoms of the pathology. can vary significantly depending on the condition of the heart, blood flow and other factors.

The most common symptoms of supraventricular tachycardia include constant dizziness and chest pain. With a prolonged attack, the patient shows signs of cardiovascular insufficiency in the form of shortness of breath, swelling of the limbs and face, changes in the skin to pale blue.

A prolonged attack often leads to fainting, as a result of which only the attending physicians can help the patient. In this case, it is imperative to measure blood pressure, since a prolonged attack provokes its decrease, and this is fraught with mortal danger - the development of collapse.

People with low blood pressure should be wary of their condition. In such people, there is a shortage of blood entering the heart and the organ itself tries to compensate for its condition by increasing the number of contractions.

Diagnostics

When contacting a doctor, the patient should tell in detail about his health problems.

On the ECG

As already mentioned, they are used to diagnose supraventricular tachycardia. Here, experts pay attention to the fact that with pathology there are no changes in the QRS. The most informative indicator is re-entry in the atrioventricular node - the cause of the development of pathology.

Re-entry occurs as a result of longitudinal dissociation into two pathways that are functionally separated. So, during an attack, an impulse along one path passes anterograde, and along the second - retrograde. It is this fact that leads to the simultaneous excitation of the ventricles with the atrium.

Re-entry stops when . The formed block in the bundle of His does not affect the development of supraventricular tachycardia. Similar phenomena are diagnosed in young people, but extremely rarely, so re-entry indicators are indirect and unreliable.

Re-entry in the sinus node also rarely indicates the onset of pathology. The impulses in this case pass in the sinus node itself, which does not lead to changes in the P waves. The atrioventricular node does not affect the propagation of the impulse, as a result of which only the properties of the node itself affect the size of the PQ interval and the presence of blockade.

Supraventricular tachycardia is often characterized by re-entry in the atrium. The impulse circulates in the atria and the QRS fixes the P wave - this indicates the presence and spread of an anterograde impulse. The re-entry circuit is not included in the atrioventricular node, so there is no effect on supraventricular tachycardia from AV blockade.

Treatment of supraventricular tachycardia

Treatment of supraventricular tachycardia begins with first aid, which is represented by pressure on the carotid node, located with right side. The node itself is located at the level of the upper border of the thyroid cartilage directly in the projection of the upper third of the sternocleidomastoid muscle. The method is called the Cermak-Gerring test.

Pressing is carried out for several seconds while the patient is in a horizontal position. At the end of the attack, the fingers are removed. Such methods are contraindicated in people with a predisposition to the development of atherosclerosis, the presence of hypertension, an overdose of drugs with digitalis.

You can use the Ashner-Dagnini test. The method consists in preventing an attack by pressing on the patient's eyeballs while he is in a horizontal position. The main thing is to follow the measures and not to press for more than half a minute. As soon as the patient begins to recover, the pressure is stopped. The sample should not be used to treat patients with eye diseases.

In addition to samples, it is recommended to use reflexology - induce vomiting in the patient or wipe him with a cold towel. If the presented methods do not work, you should resort to the use of drugs.

To stop the attack, you can use a fairly effective drug Verapamil. For relief, it is enough to inject 2 ml of 0.25% Verapamil intravenously into the patient. After the cessation of the attack, treatment is continued with tablets of the same drug using no more than 2-3 times a day.

In case of ineffectiveness of Verapamil, you can use beta-blockers, which include Anaprilin or Visken. also given intravenously up to 10 times at intervals of a few minutes if the attack persists. The introduction is carried out only under the control of the ECG. Further, the patient is treated with the use of Anaprilin tablets up to 2 times per day.

Often, Oxprenolol is used intravenously at a dosage of 0.002 g to stop an attack. This dosage is enough to stop the attack. In the future, the patient should take tablets in the amount of 2-4 pieces per day. If Visken is used, it is administered intravenously at a maximum dosage of 0.001 g. Then the patient takes 3-6 tablets per day.

You can also use Novocainomid 10% to stop an attack. It is administered intramuscularly or intravenously up to 10 ml. Until the full cessation of the attack, the patient should consume up to 1 g of the drug every two hours. But this drug is dangerous by increasing the risk of collapse.

If the patient cannot be given the above medicines, Aymalin can be used. 0.05 g of the drug is added to 10-20 ml of sodium chloride and injected slowly intravenously - at least 5 minutes. After the attack stops, the patient is allowed to use Aymalin tablets - 1-2 pieces up to 4 times a day.

Pulse-norm is an excellent drug that is recommended for use by patients who often suffer from attacks of supraventricular tachycardia. When an attack occurs, drink 2 tablets, and then one every 8-12 hours.

For quick relief of an attack, Trifosadenine, Procainamide, Esmolol and others are also suitable. But the most effective are Novocainamide or Amiodarone. Amiodarone is administered intravenously in an amount of 300 ml, previously mixed with 20 mg of 5% glucose.

After stopping the attack, the patient is prescribed the introduction or use of drugs, the action of which is aimed at preventing the formation of a relapse. It uses cardiac glycosides and antiarrhythmic drugs. Specialists combine drugs such as Diltiazem and Verapamil.

All presented drugs are prohibited for self-administration, because each person has a predisposition to the occurrence of a certain reaction to the constituent components of drugs. Some of these reactions can be fatal.

First aid

Helping the patient at the initial stages should consist of the following actions:

• help the person induce vomiting;
• squeeze the right carotid node;
• resort to squeezing the eyeballs, if there are no contraindications to this;
• pinch the patient's nose and command him to exhale;
• press on the stomach;
• bend your knees and lift them to your stomach;
• wipe with a cold towel;
• give him a sedative - valocordin or motherwort tincture;
• if nothing helps, an antiarrhythmic drug can be administered to the patient in an hour, which should be done only by a doctor.

The patient is urgently hospitalized in the clinic if he lost consciousness or had ischemic disorders

Possible Complications

With a prolonged attack, the patient often develops complications in the form of cardiogenic shock - these are disorders of blood circulation in the tissues and disturbances in consciousness.

Quite often development of heart failure with the subsequent hypostasis of lungs is noted. This is formed due to the inability to pump blood, which gradually stagnates in the pulmonary organ and seeps through blood vessels, forming a flood. In such cases, surgery is indicated to remove fluid and blood.

Due to a decrease in cardiac output and a subsequent decrease in coronary blood flow, the patient may experience an attack. In order not to provoke complications, treatment should be started on time.

Prevention

Not always when an attack occurs, treatment with the introduction of potent drugs is required. Often it is enough to prevent a second attack by giving up coffee and smoking. You should also completely eliminate from your life stressful situations, reduce physical activity (carrying weights or jogging in the morning).

Preventive measures include:

Forecast

It is necessary to talk about forecasts only after a full study of the cause of supraventricular tachycardia, the duration of the attack that occurred, and the complications formed. Here, for example, the patient may feel excellent in the presence of sinus arrhythmia physiological type.

In the presence of additional pathologies of the heart, the disease can pose a serious threat.

Patients with supraventricular tachycardia lead a normal life, and recurrent seizures resolve themselves after conservative treatment. But pathology can bring the patient to disability if the nervous system was affected in the process of complications.

Failure of the heart rhythm for a person can have negative consequences

The human heart carries out vital important features, therefore, when it fails, the whole organism is going through difficult times, which can affect the human condition. A very common failure is a violation of the heart rhythm. This is paroxysmal tachycardia, which is considered a pathological condition that looks like palpitations. They usually start suddenly, and the heart beats can range from 140 to 250 beats per minute. In addition, a person feels other symptoms, which we will also discuss in this article. However, it will not just be about tachycardia. we will discuss such a phenomenon as paroxysmal supraventricular tachycardia

Why is this phenomenon considered abnormal? In the normal state, an electrical impulse develops in the cells of the sinus node in the atrium, that is, in the upper cardiac region. Thanks to this impulse, the atrial muscles contract synchronously and push the blood into the lower heart sections, that is, into the ventricles. After that, the impulse passes to the atrioventricular node and then moves along the legs of the His bundle, as well as the Purkinje fibers to the ventricular myocardium. Due to the fact that the impulse is delayed in the atrioventricular node, the atria have time to contract, so the blood passes into the ventricles, where the impulse propagates. The ventricles contract and push out into the blood vessels into the blood.

With the deviation, which will be discussed in this article, a violation of the conduction of impulses leads to the fact that the frequency of contractions of the ventricles and atria increases. This frequency is chaotic and abrupt, which is why this phenomenon is called paroxysmal. Anomalous conduction pathways can form in different places atria, as well as near the atrioventricular node. Now that we have figured out how the heart works in the normal state and with tachycardia, it's time to understand why this happens.

Causes of the disease

Only an electrocardiographic study can reveal the exact cause of the deviation. However, it is possible to identify common causes that can lead to the development of paroxysmal supraventricular tachycardia. Most often, it develops due to the presence of various diseases. They may be:

Angina pectoris can cause disease

cardiosclerosis;

Paroxysms of supraventricular tachycardia may occur due to the use of diuretics. In addition, this condition can occur in pregnant women and children.

The period of pregnancy is accompanied by a greater load on all organs, and, of course, on the heart, which now has to work in an enhanced mode. It often happens that supraventricular tachycardia becomes a complication of certain conditions of a pregnant woman. For example, this may be due to anemia, water-salt imbalance, hypertension, or high hormonal levels. If these conditions are eliminated, tachycardia may cease to manifest itself altogether.

In children and adolescents, paroxysmal tachycardia often does not have causes associated with organic heart disease. Usually the reasons are:

• electrolyte disturbances;
• physical or psycho-emotional stress;
• unfavorable conditions, such as high humidity in the nursery, fever body, unventilated area.

Main symptoms

The attack begins with a feeling of "shock" in the heart

At the beginning, we mentioned that tachycardia is manifested by seizures. They are usually pretty obvious. The attack begins with a feeling of "shock" in the heart. During the attack, it is also felt general malaise, retrosternal pain, weak pulse, rapid breathing, fear, slight dizziness, aphasia and hemiparesis.

External signs may also appear, such as pale skin and sweating. Recall that the attack begins suddenly, and its duration can be either a few hours or several days or even weeks.

Diagnosis of the disease

First of all, the patient should describe his condition in detail. If there are attacks of a sharp heartbeat, a special examination is carried out, which helps to make the correct diagnosis. Paroxysms of supraventricular tachycardia can be detected by several methods.

Diagnosis should begin with a physical examination

Physical examination. Paroxysmal tachycardia is characterized by a rigid rhythm, that is, it will not depend on physical activity or breathing intensity. Therefore, it is important to conduct an auscultatory examination, which helps to identify rhythmic heart sounds.

Treatment

Once supraventricular tachycardia has been identified, it's time to start treatment. To begin with, let's see how to provide emergency care in case of an attack.

Carotid sinus massage

It is best to provide such assistance by trying to exert a reflex effect on the vagus nerve. This can be achieved if the patient performs straining at the height of a deep breath. In addition, you can act on the carotid sinus zone by massaging the carotid sinus. It is advised to do this if the patient lies on his back, pressing the carotid right artery. You can also press on the eyeballs, although this method is less effective.

If these methods do not provide desired effect medicines should be used. However, before using them, you should consult your doctor. The most effective is verapamil, which is administered intravenously. Also useful is the use of adenosine triphosphate, which is also administered intravenously. The use of isotonic sodium chloride solution can reduce pressure. For this reason, in the event of an attack of tachycardia, which is accompanied by arterial hypotension, it is advised to use novocainamide together with a mezaton solution.

These are not the only drugs that can be used to combat paroxysms of supraventricular tachycardia. The doctor may allow the use of such drugs as aymalin, propraponol, disopyramide, digoxin, amiodarone.

Electrical stimulation of the heart using an esophageal electrode

Even if this drug therapy does not bring the expected result, the doctor may prescribe other methods. This includes electropulse therapy and electrical stimulation of the heart using an endocardial and esophageal electrode. Electrocardiostimulation is carried out using a probe-electrode. It is injected through the veins into the cardiac sections on the right. The pulse rate of the stimulator is approximately ten percent higher than the heart rate during paroxysm, then it is gradually reduced until the rhythm returns to normal.

When treating, it is necessary to take into account the form of paroxysms of supraventricular tachycardia. For example, if it is associated with digitalis intoxication, then in no case should cardiac glycosides be used. If there is ectopic atrial tachycardia, then vagus nerve stimulation methods are not very effective.

Possible consequences

Tachycardia attacks can cause cardiogenic shock

If an attack of tachycardia continues for a long time, complications similar to cardiogenic shock may develop. which means a disorder accompanied by impaired consciousness, as well as disorders of the blood circulation in the tissues.

Heart failure may also develop, and subsequently pulmonary edema, since the heart cannot cope with pumping blood, it stagnates in the lungs, it liquid part seeps through the blood vessels and floods the lungs.

In addition, an attack of angina pectoris can occur, as the value of cardiac output decreases, and because of this, coronary blood flow decreases. Supraventricular tachycardia, of course, is not as dangerous as the ventricular form, but complications can still occur and, as we have seen, they can be very dangerous for a person. It is because of these consequences that treatment must be started on time. But it is best to try to prevent the disease.

Preventive measures

The best prevention is a healthy lifestyle. This means that you need to get rid of bad habits such as smoking and alcohol abuse. You should also try to avoid mental and physical stress. If seizures begin, you need to provide assistance in time and find out the cause of their occurrence.

By being attentive to your lifestyle and conducting an examination on time, it will be possible to avoid serious health problems. The rhythm of the heart will be able to recover, you just need to make every effort for this.

Treatment of paroxysmal supraventricular tachycardia

The clinical spectrum of paroxysmal supraventricular tachycardia is quite wide. The frequency of seizures in patients with PSVT varies significantly. Moreover, the severity of symptoms during PSVT depends on the frequency of tachycardia, the presence or absence of comorbid heart disease, and the duration of the attack. Many patients with infrequent or well-tolerated seizures do not require treatment. However, in most cases, treatment is necessary to stop an acute attack of tachycardia or prevent recurrent attacks.

Relief of an acute attack

The essence of the method of arresting an acute attack of PSVT can be explained by the example of circulation involving an abnormal pathway. The circular movement of the excitation (and hence the PVT) continues as long as the closed path along which the wave travels remains excitable (Fig. 10.5). If the wave on its way collides with refractory tissue and is blocked, the circular motion is interrupted and the tachycardia attack stops (see Fig. 10.5). In a patient with an acute attack of tachycardia, the goal of therapy is to increase the refractoriness of the anterograde link of the pathway (normal pathway) or retrograde link (abnormal pathway), sufficient to block the circulating wave. These considerations are also valid in the case of AV nodal circulation, where the goal of treatment is to increase the refractory period in the fast or slow path at the AV node.

Several different techniques are used to stop an acute attack of PSVT. The first effect is usually applied to the parasympathetic nervous system, for example massage of the carotid sinus (or sinus of Valsava). Such an effect can sufficiently increase the refractoriness of the AV node and stop the attack of tachycardia. To increase refractoriness in one of the links of the closed chain, intravenous administration of drugs is also used. Verapamil, cardiac glycosides, and beta-blockers can increase the refractoriness of the AV node, and procainamide can increase the refractoriness of the abnormal retrograde pathway or retrograde fast pathway in the AV node (in the normal variant of the AV nodal circulation). In daily practice, the drug of choice is verapamil (intravenous administration of 5-10 mg), since in 90% of cases it allows you to stop circulation involving the abnormal pathway or AV nodal circulation within a few minutes, and side effects are observed very rarely. The effectiveness of intravenous administration of cardiac glycosides, beta-blockers and procainamide in this situation has not been established. However, even if these drugs are effective, they usually act more slowly than verapamil.

Rice. 10.5. The conduction system in Wolff-Parkinson-White syndrome (see Fig. 10.2).

A - circulation using the anomalous path. B - the circulatory movement of the wave is blocked in the antegrade link due to an increase in the refractoriness of the AV node. B - the circulation of impulses is blocked in the retrograde link due to the increased refractoriness of the abnormal conduction pathway.

Attacks of PSVT are usually associated with the circulation of excitation, so they can be stopped with stimulation.

If the place and frequency of stimulation are chosen correctly, then the evoked excitation can penetrate the closed circuit and make it refractory. To stop a single episode of PSVT, the insertion of a catheter electrode is usually required. However, the development of artificial pacemakers triggered by a radio signal made it possible to use permanent electrodes implanted in the heart and ensuring the cessation of recurrent attacks of PSVT. This method of treatment is used, as a rule, in patients with resistance (or intolerance) to existing oral forms of antiarrhythmic drugs. Prior to the implantation of a radio-controlled pacemaker, it is necessary to conduct electrophysiological studies to establish that tachycardia is indeed associated with the circulation of excitation and the proposed position of the electrode ensures the penetration of the evoked excitation into a closed circuit. To stop attacks of PSVT, which are very poorly tolerated or refractory to other forms of treatment, exposure to a powerful direct current pulse can be used.

Relatively little is known about the treatment of patients with rarer variants of PSVT. The sinoatrial circulation can often be controlled with carotid sinus massage. Automatic ectopic atrial tachycardia is usually resistant to medical treatment. However, in this situation, the administration of verapamil, cardiac glycosides, or beta-blockers can sufficiently increase the refractoriness of the AV node and normalize the ventricular rhythm (BCA with block).

Relapse Prevention

Some patients with recurrent episodes of PSVT require treatment to prevent another attack. In most cases, oral antiarrhythmic drugs are prescribed to maintain an increased refractoriness in some part of the closed circuit, which prevents the circulation. Drugs used for this purpose include cardiac glycosides, beta-blockers, verapamil, procainamide, quinidine, and disopyramide. Any of these drugs may be effective, so none of them is preferred. Verapamil given orally to prevent recurrent attacks of PSVT is not as often effective as intravenous administration in relieving an acute attack.

If recurrent episodes of PSVT are not accompanied by severe symptoms, trial and error is the most prudent choice of therapy. Since any of the available antiarrhythmics may be effective, the clinician should start with the drug (or combination of drugs) that is most likely to be well tolerated in the patient. Therefore, trial therapy is often initiated with cardiac glycosides or beta-blockers, given alone or in combination. If they are ineffective in preventing recurrence, one of the class I antiarrhythmic drugs can be prescribed. Using the trial and error method allows you to choose an effective drug therapy in a reasonable time.

Rice. 10.6. Recordings obtained from serial electrophysiological studies using drugs in a patient with paroxysmal supraventricular tachycardia due to impulse circulation in the AV node (common variety).

Each fragment (A - E) shows an ECG in lead II and an electrogram of the upper part of the right atrium (RAI). Paroxysmal tachycardia was induced by atrial pacing (arrows). Induced tachycardia persisted > in control studies (A), after administration of ouabain (B), and after administration of propranolol (C). With the simultaneous administration of ouabain and propranolol (D), the induced tachycardia was unstable due to the block of anterograde conduction along the slow pathway (the last reflected atrial excitation (E) is not accompanied by a QRS complex). After the administration of procainamide (D), the induced tachycardia was also unstable, but this time due to a block of retrograde conduction along fast track(the last QRS complex is not associated with atrial echo).

I47.1 Supraventricular tachycardia: description, symptoms and treatment

supraventricular arrhythmia- recurring attacks of rapid heartbeat, starting in the upper chambers of the heart. Mostly seen in children. Sometimes it runs in families. Risk factors are exercise, alcohol and caffeine abuse. Gender doesn't matter.

Supraventricular tachycardia (SVT) is a form of arrhythmia caused by a violation of electrical conduction and regulation of heart rate. During an attack SVT. which can last several hours, the heart beats fast but steady. The heart rate reaches 140-180 beats per minute, and sometimes more. AT healthy heart each contraction is initiated by an electrical impulse from the sinoatrial node (pacemaker) located in the right atrium (upper chamber of the heart).

The impulse then travels to the second node, which sends the impulse to the ventricles. At SVT the sinoatrial node does not control heart contractions, both due to the formation of pathological conduction paths along which the electrical impulse constantly circulates between the atrioventricular node and the ventricles, and due to the formation of an additional node that sends additional impulses that disturb the heart rhythm. SVT may first appear in childhood or adolescence, although the disease can occur at any age. In some cases, the reason SVT- congenital disorder of the conduction system of the heart. Attacks begin for no apparent reason, but they can be triggered by exercise, caffeine and alcohol.

Symptoms SVT usually appear suddenly. They can last from a few seconds to hours. Among them:

- cardiopalmus;

- dizziness;

- Pain in the chest or neck.

Complication SVT is heart failure. In some cases, prolonged SVT can lower blood pressure to dangerous levels.

If the doctor suggests SVT. the patient will be sent for an ECG to record the electrical activity of the heart. These studies last 24 hours or more because SVT appears periodically. Additional studies are possible to identify the pathology of the conduction system of the heart.

For prolonged and severe attacks SVT urgent hospital treatment is required. At the hospital, the patient will be given oxygen and intravenous injections of antiarrhythmic drugs. In some cases, electrical impulse therapy is performed to restore a normal heart rhythm.

Patients with short and infrequent attacks SVT can control heart rate by stimulating the vagus nerve. One of the methods of such stimulation is rubbing the skin on the neck over the carotid artery, although this is not recommended for people over 50 years of age - this can provoke a stroke. You can also wash your face with ice-cold water or start pushing, as with a bowel movement. The doctor will talk about these methods of stimulation. severe seizures SVT can be treated with a long course of antiarrhythmic drugs. Also for treatment SVT radiofrequency ablation is used, which is performed during electrophysiological studies. At the same time, pathological pathways are destroyed, but there is a danger of a complete blockade of the conduction system of the heart. In most cases SVT does not affect life expectancy.

Synonyms of the nosological group:

• Supraventricular paroxysmal tachycardia
• Supraventricular tachyarrhythmia
• Supraventricular tachycardia
• Supraventricular arrhythmias
• Supraventricular paroxysmal tachycardia
• Supraventricular tachyarrhythmias
• Supraventricular tachycardia
• Neurogenic sinus tachycardia
• orthodromic tachycardias
• Paroxysmal supraventricular tachycardia
• Paroxysm of supraventricular tachycardia
• Paroxysm of supraventricular tachycardia in WPW syndrome
• Paroxysm of atrial tachycardia
• Paroxysmal supraventricular tachyarrhythmia
• Paroxysmal supraventricular tachycardia
• Polytopic atrial tachycardia
• Atrial arrhythmia
• Atrial true tachycardia
• Atrial tachycardia
• Atrial tachycardia with AV block
• Reperfusion arrhythmia
• Berzold-Yarish reflex
• Recurrent sustained supraventricular paroxysmal tachycardia
• Symptomatic ventricular tachycardias
• Sinus tachycardia
• Supraventricular paroxysmal tachycardia
• Supraventricular tachyarrhythmia
• Supraventricular tachycardia
• Supraventricular extrasystole
• Supraventricular arrhythmias
• Tachycardia from the AV junction
• Supraventricular tachycardia
• Tachycardia orthodromic
• Sinus tachycardia
• Nodal tachycardia
• Chaotic polytopic atrial tachycardia
• Wolff-Parkinson-White Syndrome

Paroxysmal supraventricular tachycardia (PNT) is one of the types of arrhythmia, which is characterized by a sudden paroxysmal increase in the frequency of contractions of the heart muscle. Heart rate increases to 140 - 250 beats per minute, while the correct rhythm of the heartbeat is maintained.

The occurrence of PNT is associated with the activation in the myocardium of a highly active ectopic focus of automatism or a focus of post-depolarization trigger activity. In the vast majority of cases, PNT is based on the mechanism of impulse re-entry and circular circulation of excitation through the myocardium (or the so-called re-entry reentry mechanism). In any of these cases, the occurrence of PNT contributes to the preliminary appearance of extrasystole.

ICD-10 code

I47 Paroxysmal tachycardia

I47.1 Supraventricular tachycardia

Of all types of arrhythmias, in 95% of cases, it is PNT that occurs in children. In patients under 18 years of age, PNT is the most common cause leading to arrhythmogenic collapse and heart failure. For every 1000 people in the population, there are 2.29 patients with PNT. In women, this disease occurs twice as often as in men. The risk of developing tachycardia increases at the age of more than 65 years - a five-fold increase in patients who have crossed this age limit is recorded.

With any mechanism for the occurrence of paroxysmal supraventricular tachycardia, extrasystole preliminarily develops. Extrasystole is the most common type of arrhythmia, which manifests itself as a violation of the heart rhythm and is characterized by the occurrence of single or paired premature contractions of the heart (extrasystoles). Arrhythmic contractions of the heart muscle are caused by excitation of the myocardium, which comes from the pathogenic focus of excitation. The disease is functional (neurogenic).

The causes of paroxysmal supraventricular tachycardia of an organic nature are as follows:

1. Organic damage to the heart muscle and conduction pathways of the heart, which are inflammatory, dystrophic, necrotic and sclerotic. Such damage occurs in acute myocardial infarction, chronic coronary heart disease, heart defects, cardiopathy, myocarditis.
2. The presence of additional abnormal conduction pathways, for example, in Wolff-Parkinson-White syndrome.
3. Presence of additional viscerocardinal reflexes and mechanical influences (eg, additional chords, prolapse mitral valve, spikes).
4. The emergence of pronounced vegetative-humoral disorders in the syndrome of neurocircular dystonia.

The above violations are called intracardiac factors for the occurrence of PNT.

Experts believe that the presence of certain structural features of the heart or damage is not enough for the occurrence of paroxysmal supraventricular tachycardia. In the development of this disease, psychoemotional factors play an important role. It is known that increased sympathoadrenal activity leads to various forms of ectopic arrhythmias.

In childhood and adolescence, it is often difficult to diagnose the causes of paroxysmal tachycardia. In these cases, the presence of a violation of the contractions of the heart muscle is defined as essential (or idiopathic). Although, experts believe that the causes of paroxysmal supraventricular tachycardia in such patients are minimal, undiagnosed dystrophic damage to the myocardium.

Like extrasystole, PNT can also occur in healthy people due to pathogenic factors. With intense physical or mental stress, with strong and long-term stress. These reasons are called extracardiac. These factors also include smoking and alcohol abuse, strong tea, coffee and spicy food.

When tachycardia appears, it is necessary to check the level of thyroid hormones in the blood. Although thyrotoxicosis is almost never the only cause of PNT. But when choosing a therapy, difficulties may arise that are associated with the need to stabilize the hormonal level.

Disease of some other organs can cause paroxysmal tachycardia. For example, kidney prolapse and others kidney disease, lung diseases (acute, and especially chronic), dysfunction and diseases of the gastrointestinal tract. The above diseases of the internal organs are extracardiac factors; as a result of the transfer similar diseases paroxysmal supraventricular tachycardia occurs as a complication.

The clinical picture of the manifestation of paroxysmal supraventricular tachycardia is characterized by the presence of the following symptoms:

1. The palpitations begin with a "thump" or "prick" in the heart, a sensation of stopping or turning over.
2. The heart rate rises to 250 beats per minute.
3. There are interruptions in the beating of the heart.
4. Pulse has weak filling often cannot be felt.
5. There is unmotivated anxiety, shortness of breath, weakness, dizziness, noise in the head, sweating.
6. There is pain in the chest area or angina pectoris occurs.
7. With a pronounced tachycardia, blood pressure decreases.
8. During an attack, the pulse has a constant stable frequency that does not change over time.
9. There is frequent and profuse urination; manifestations of flatulence are possible.

The minimum duration of paroxysmal supraventricular tachycardia is three cardiac cycles. Such manifestations are called "jogging" tachycardia. Usually, attacks of paroxysmal supraventricular tachycardia last from several hours to several days. Perhaps a longer manifestation of tachycardia, up to several months,

Symptoms of supraventricular paroxysmal tachycardia most often disappear spontaneously and on their own. In some cases, with seizures that last for several days, a fatal outcome is possible if no treatment measures are applied.

There are two main types of paroxysmal tachycardia:

• ventricular (ventricular).
• supraventricular (supraventricular).

This classification arose due to the focus of localization of pathological excitation. PNT, in comparison with the gastrointestinal tract, proceeds more gently and favorably; more cases of positive dynamics are also recorded in the treatment of PNT. Since paroxysmal supraventricular tachycardia is less often associated with organic heart disease and left ventricular dysfunction. And yet, PNT potentially poses a threat to life, since it is characterized by sudden manifestations that can lead to disability of the patient or his death (in 2-5% of cases).

Paroxysmal supraventricular tachycardia has two subspecies:

• atrial paroxysmal tachycardia - in 15-20% of cases.
• atrioventricular (atrioventricular) paroxysmal tachycardia - in 80-85% of patients.
• The division into subtypes of PNT is due to the localization of the pathological zone or the circulating wave of excitation.

According to the nature of the course of the disease, three forms are distinguished:

• acute (paroxysmal).
• constantly recurrent (chronic).
• continuously recurring, which constantly develops over several years.

Considering the mechanism of the development of the disease, there are three types of PNT:

• reciprocal (associated with the re-entry mechanism in the sinus node).
• ectopic (or focal).
• multifocal (or multifocal).

The diagnosis of "paroxysmal supraventricular tachycardia" is established if the patient complains of sudden attacks of rapid, sharp heartbeat. Confirmation can be obtained using the following methods: physical examination and instrumental diagnostics.

At the initial stage, it is enough to collect an anamnesis. A characteristic sign for PNT is the occurrence of a heartbeat, "as if on the flip of a switch." When examining a patient, it is important to find out how suddenly a violation of the rhythm of the heartbeat occurs. At the beginning of the collection of data on the onset of symptoms, patients may claim that the failure in the heartbeat occurs suddenly. But with a detailed and thorough questioning of patients, it sometimes turns out that the change in the rhythm of heart contractions occurs gradually, over several minutes. These symptoms are characteristic of another disease called sinus tachycardia.

PNT is diagnosed using external signs and autonomic manifestations of the disease. This type of tachycardia is characterized by increased sweating, frequent urination, nausea, dizziness, noise in the head, and so on.

Physical examination

If, during auscultation, the heart rate exceeds 150 beats per minute, then this excludes the diagnosis of sinus tachycardia. A heart rate of more than 200 beats per minute disproves the diagnosis of gastric tachycardia. But auscultation does not reveal the source of tachycardia, and also does not always distinguish sinus tachycardia from paroxysmal.

When measuring the pulse, it is almost impossible to count it, it is so frequent. In this case, the pulse is soft and weakly filled.

During the physical examination, vagal tests are used. They are mechanical stimulation of the vagus nerve receptors, which is carried out in the form of pressure. This procedure causes a rapid and reflex increase in the tone of the above nerve. With vagal tests, the method of pressure on the carotid sinus, the Valsalva test, pressure on the eyeball, and other methods are used.

The vagus nerve is connected to the atrium and the atrioventricular node. Increased tone nerve slows down the frequency of atrial contractions and atrioventricular conduction, resulting in a decrease in the frequency of contractions of the ventricles of the heart. This facilitates the interpretation of the supragastric rhythm, which allows for the correct diagnosis of tachycardia. Can be held complex diagnostics, which increases the value of vagal samples. In this case, continuous ECG and cardiac auscultation are performed along with vagus nerve stimulation. Such diagnostics are carried out before, during and after vagal tests. With PNT, a sudden stop of arrhythmic contractions occurs and sinus rhythm is restored. In some cases, during the diagnosis, there are no changes in the frequency of contraction of the heart muscle. This is due to the “all or nothing” law, which is characteristic of the clinical picture of the course of this type of tachycardia.

At the same time, it must be remembered that vagal tests can provoke unforeseen complications not only in patients, but also in healthy people. There are a number of cases that have ended in death. In rare cases, with pressure on the carotid sinus in elderly patients, thrombosis of the cerebral vessels may occur. Stimulation of the vagus nerve can lead to a decrease in cardiac output. And this, in turn, in some cases leads to a sudden decrease in blood pressure. There may be an attack of acute left ventricular failure.

Instrumental diagnostics

Instrumental diagnosis of PNT is carried out using the following methods:

1. Study of the work of the heart using an electrocardiogram.
2. Holter monitoring.
3. Stress ECG tests or stress test.
4. Echocardiography.
5. Transesophageal stimulation of the heart.
6. Intracardiac electrophysiological study.
7. Magnetic resonance imaging (MRI) of the heart.
8. Multispiral CT-cardiography (MSCT of the heart).

Supraventricular paroxysmal tachycardia on ECG

One of the main methods for diagnosing paroxysmal tachycardia is electrocardiography.

Conducting an electrocardiogram is a non-invasive method of research, which has proven itself to be quick and painless. The essence of this method is to check the electrical conductivity of the heart. On the body of the patient - his chest, arms and legs - 12 electrodes are placed, thanks to which it is possible to obtain a schematic image of the activity of the heart at different points. With the help of an electrocardiogram, you can establish the diagnosis of PNT, as well as identify its causes.

Supraventricular paroxysmal tachycardia on the ECG has the following signs, which are clearly visible on the electrocardiogram tape:

1. The sharp initial appearance of paroxysm and the same end of the attack.
2. There is a heart rate of more than 140 beats per minute.
3. Regular heartbeat.
4. Usually, QRS complexes are normal in appearance.
5. The P waves are different on visual diagnosis. With paroxysmal tachycardia of the atrioventricular form, the P waves are located after the QRS complexes or are layered on them. In atrial PT, P waves are located in front of the QRS complexes, but have an altered or deformed appearance.

Emergency care for paroxysmal supraventricular tachycardia

Some attacks of PNT require urgent medical attention, because the attack does not go away on its own, and the patient's condition worsens. Treatment is provided on the spot by an ambulance team that arrives. If an attack of paroxysm occurred for the first time or there are suspicions for the hospitalization of the patient, an additional cardiological ambulance team is called. In doing so, apply following methods emergency care for paroxysmal supraventricular tachycardia:

• The use of vagal samples helps to stop the attack. First of all, the Valsalva test is used when you need to strain and hold your breath for 20 or 30 seconds. This is the most effective test. Deep, rhythmic breathing can also help. The Ashner test is also used, which is pressure on the eyeballs for five seconds. You can also squat down. The use of vagal tests is contraindicated in the following diseases: conduction disorders, severe heart failure, sick sinus syndrome, stroke, dyscirculatory encephalopathy, glaucoma.
• If the face is in cold water for 10–20–30 seconds, this will help stop an attack of PNT.
• Massage one of the carotid sinuses. Massage is contraindicated if there is a sharp decrease in heart rate and there is noise over the carotid artery.
• If all of the above actions did not give a result, then you need to stop the attack with the help of transalimentary cardiac stimulation (CHPSS) or electrical impulse therapy (EIT). CHPSS is also used in case of impossibility of using arrhythmic drugs due to intolerance. The use of CPSS is indicated in the presence of data on conduction disturbance during the recovery from an attack.
• To most effectively stop an attack of PVT, it is necessary to determine its form - PVT with narrow or wide QRS complexes.
• In PNT with narrow QRS complexes, the following drugs must be administered intravenously: adenosine phosphate, verapamil, procainamide, and others. Without an electrocardiographic examination, the use of drugs is possible only in extreme, critical cases. Or when there is evidence that the drug has been used on the patient during previous attacks, and the procedure has not brought complications. Required constant control for the patient's condition using an ECG. If there is no effect from the administration of drugs, then you need to use chewed tablets, namely propranolol, atenolol, verapamil and others. In any case, these procedures are carried out only by the ambulance team that came to the patient.
• In an attack of PNT with wide QRS complexes, there is a suspicion of paroxysmal ventricular tachycardia. Therefore, the tactics of arresting an attack in this case are somewhat different. Electropulse therapy is effective, as is transalimentary stimulation of the heart. Drugs are used that stop both attacks of supraventricular and ventricular PT. The most commonly used drugs are procainamide and/or amiodarone. For unspecified wide complex tachycardia, adenosine, aimaline, lidocaine, sotalol are used.

Indications for hospitalization of the patient are as follows:

• An attack of PNT cannot be stopped on the spot.
• An attack of PNT is accompanied by acute cardiac or cardiovascular failure.

Patients who have PNT attacks occur at least 2 times a month are subject to mandatory planned hospitalization. In the hospital, the patient undergoes an in-depth diagnostic examination, during which he is prescribed treatment.

Treatment of paroxysmal supraventricular tachycardia

Mode and diet

• With the manifestation of tachycardia, you should lead a certain lifestyle.
• First of all, you must stop smoking and drinking alcohol.
• It is necessary to monitor the maintenance of an even psycho-emotional state during the day and avoid stress. To strengthen the psyche is useful to do autogenic training and other types of self-regulation. It is also possible to use sedatives prescribed by a doctor.
• It is necessary to adhere to a stable daily routine, get enough sleep and not stay up late watching TV or chatting on social networks. There should be enough time during the day for rest or naps if needed by the patient.
• Include feasible physical activity in your daily routine, namely, morning exercises, nightly walks in the fresh air, swimming in the pool or open water.
• Be sure to monitor your cholesterol and blood sugar levels.
• It is necessary to maintain optimal body weight.
• Food should be taken in small portions 4-5 times a day. Because an overfilled stomach begins to irritate the receptors of the nerves responsible for the work of the heart, which can lead to an attack of tachycardia.
• To avoid overeating, you need to exclude reading books, watching TV and working at the computer while eating. When the focus is only on the process of absorption of food, it is much easier to feel full in time to stop.
• Do not eat food at night; It is advisable to spend the last meal two to three hours before bedtime.

From the use it is necessary to exclude products that provoke the appearance of tachycardia:

• tea and coffee.
• foods containing starch and sugar, high-calorie foods- pastries, chips, crackers, chocolate bars, sweets and so on.
• fatty foods- fatty meat, mayonnaise, sour cream, lard, margarine; It is worth limiting the consumption of butter.

Most of these products contain "bad" cholesterol, which negatively affects the condition of the heart muscle.

It is necessary to minimize the consumption of salt, if necessary, replacing it with spices (for example, dried sea ​​kale). Salt should only be added to cooked foods.

You should also exclude from the diet:

• canned and refined foods, as they contain a large amount of fats, salt and other foods that are dangerous for the heart.
• fried food.

The diet for patients with paroxysmal supraventricular tachycardia should include a large amount of low-fat and plant foods.

You need to include in your diet following products that support healthy heart function:

• foods rich in magnesium and potassium - dried apricots, buckwheat porridge, honey, pumpkin, zucchini.
• foods containing omega 3 unsaturated fatty acids - sea ​​fish, flaxseed, walnuts, canola oil.
• foods containing omega 6 unsaturated fatty acids - vegetable oils, various seeds and soy.
• monounsaturated fats - they are found in sufficient quantities in cashews, almonds, peanuts, avocados and oils from various types of nuts.
• products with low content fat - skimmed milk, yogurt and cottage cheese.
• various types of cereals, which contain a large amount of nutrients, as well as fresh and stewed vegetables.
• it is necessary to introduce a certain amount of freshly squeezed juices into the diet, as they are rich in vitamins and minerals.
• There are several useful recipes that should be included in the diet of patients with tachycardia.
• Take 200 grams of dried apricots, walnuts, raisins, lemon and May honey. Grind everything and mix in a blender, pour into a jar and store in the refrigerator. Take one tablespoon twice a day.
• A good remedy for tachycardia is celery root. You need to prepare salads with it: grate it on a coarse grater and add greens - celery leaves, dill and parsley. Salad must be salted and seasoned with low-fat yogurt (or put a small amount of low-fat sour cream).

Medical treatment of paroxysmal supraventricular tachycardia

It must be remembered that taking medications, as well as their dosage, is prescribed by a doctor.

In the treatment of PNT, sedative drugs are used: tranquilizers, bromine, barbiturates.

Drug treatment begins with the use of beta-blockers:

• Atenolol - a daily dose of 50-100 mg in 4 doses or propranolol (anaprilin, obzidan) - a daily dose of 40-120 mg in 3 doses.
• Metoprolol (vasocardin, egilok) - 50-100 mg 4 times a day.

Quinidine is prescribed for patients who do not have myocardial damage and heart failure. The average dose is 0.2 - 0.3 grams 3-4 times a day. The course of treatment is several weeks or months.

Quinidine bisulfate (quinidine dureter, quinidine duriles), as the latest generation drugs, cause less side effects from the gastrointestinal tract, and also have a higher concentration in the patient's blood. Quinidine dureter is applied at 0.6 grams 2 times a day.

In the treatment of patients with affected myocardium and heart failure, as well as pregnant women, it is recommended to use digitalis preparations - isoptin. The daily dose of the drug is from 120 to 480 mg per day and is used in 4 doses. It is good to use the drug digoxin - 0.25 grams per day.

The best results are obtained by combining digitalis and quinidine preparations.

The drug procainamide is prescribed for use as follows: 1 or 2 tablets, dosage of 0.25 grams, 4 times a day.

The following drugs are also prescribed:

• Aymalin - 50 mg 4-6 times a day.
• Verapamil - 120 mg 3-4 times a day.
• Sotalol - 20 - 80 mg 3-4 times.
• Propafenone - 90 - 250 mg, 3-4 times a day.
• Allapinin - 15 - 30 mg, 3-4 times a day.
• Etatsizin - 50 mg, 3 times a day.

Experts recommend a long course of treatment with potassium preparations; potassium chloride, panangin, tromkardin are used. These drugs are prescribed in combination with some of the main antiarrhythmic drugs. Potassium chloride in a 10% solution is used at a dosage of 20 ml 3 or 4 times a day during a long course of treatment.

Physiotherapy for paroxysmal supraventricular tachycardia

In the treatment of paroxysmal supraventricular tachycardia, water procedures are actively used:

• medicinal baths.
• whirlpool tubs.
• dousing.
• rubbing.
• circular shower.

Treatment of paroxysmal supraventricular tachycardia by folk methods

It happens that patients suffering from paroxysmal supraventricular tachycardia are contraindicated in some drugs prescribed by a doctor. Traditional medicine will come to the aid of patients. Here are a few recipes that patients can easily use to alleviate their condition.

• Using lovage: you need to take 40 grams of plant roots and pour 1 liter of hot water (but not boiling water). The infusion must be kept for 8 hours, and then filtered. Take the drink throughout the day in small portions until the state of health improves.
• Pour three glasses of viburnum berries into a three-liter jar and pour two liters of boiling water. After that, you need to carefully close the jar, wrap it up and leave for six hours. Then it is necessary to strain the infusion into an enamel bowl and also squeeze the berries there. Then add 0.5 liters of high-quality honey to the infusion and refrigerate for storage. Take an infusion before meals three times a day, one third of a glass. The course of treatment is one month, then you need to take a break of ten days and repeat the infusion. Thus, it is necessary to carry out three courses of treatment.
• The method of treating hawthorn has also proven itself. In the pharmacy, you should purchase alcohol tinctures of hawthorn, motherwort and valerian (one bottle each). Next, you need to mix the tinctures thoroughly and leave for one day in the refrigerator. Take the medicine three times a day for a teaspoon half an hour before meals.
• It is good to use rosehip infusion in the treatment of tachycardia. It is necessary to take 2 tablespoons of wild rose, place them in a thermos and pour half a liter of boiling water. Leave to brew for one hour, and then add 2 tablespoons of hawthorn. The resulting infusion should be drunk in small portions throughout the day and a fresh drink should be brewed daily. Within three months it is necessary to drink the infusion, and then take a break for one year.

Treatment of paroxysmal supraventricular tachycardia at home

With an attack of paroxysmal tachycardia, you need to resort to self-help and mutual assistance:

• First of all, you need to calm down, the most important thing at this moment is to acquire physical and emotional peace.
• With a sharp weakness, nausea and dizziness, it is necessary to sit in a comfortable position or lie down in a horizontal position.
• Need to ensure penetration fresh air to the patient. To do this, unbutton clothes that hold your breath, as well as open a window.
• An attack of paroxysmal tachycardia can be removed by irritating the vagus nerve using reflex methods. To do this, you need to perform the following exercises: strain to squeeze the abdominal press; press on the eyeballs; hold your breath for 15-20 seconds; induce vomiting.
• If the attending physician has shown how vagal tests are performed, it will be useful to conduct them.
• It is necessary to take the drugs prescribed by the doctor and in no case change the dosage of the medication on your own.
• If the state of health and well-being worsens, then you need to urgently call an ambulance. If there is pain in the heart, sudden weakness, suffocation, loss of consciousness and other signs of deterioration, medical attention should be called immediately.

Treatment of paroxysmal supraventricular tachycardia requires the restoration of the required concentration in the blood, the so-called electrolyte substances. These include potassium, calcium and chlorine. Choosing the right therapy medicinal herbs, then the organism enough will receive necessary substances, as well as vegetable glycosides.

In paroxysmal tachycardia, plants containing cardiac glycosides and having a sedative (sedative) effect are widely used. These include hawthorn, motherwort, valerian, mint, lemon balm. They need to be used for a long time in courses with certain breaks in the form of decoctions and infusions. There are also alcohol analogues of medicinal tinctures, but due to the presence of alcohol in the preparation, they can not be used by all patients. In any case, before taking herbs, you should consult with your doctor. Since there are contraindications for taking various means traditional medicine, as well as their incompatibility with pharmaceutical preparations prescribed by the doctor.

With attacks of paroxysmal tachycardia, breathing techniques should be used. For example, "yogic breathing" well stops attacks of accelerated heartbeat. A breathing exercise is performed as follows: inhale through one nostril (while closing the other nostril with your finger) - exhale through the other nostril.

Another modification of the breathing technique is possible, in which inhalation and exhalation are performed rhythmically, with a breath hold. For example, inhale for 3 counts, hold for 2 counts, exhale for 3 counts, hold for 2 counts.

It is good to learn breathing exercises according to the Strelnikova method or Buteyko breathing. These techniques do not eliminate the cause of the disease, but they can alleviate the patient's condition, and also contribute to the training of the heart muscle, which significantly reduces the number and duration of attacks.

Surgical treatment of paroxysmal supraventricular tachycardia

This method is used if conservative treatment has shown to be ineffective. Also, with irreversible sclerotic changes in the heart and with the detection of heart disease, surgery is recommended.

There are two types of surgical treatment - partial and radical. With a radical method of treatment, the patient permanently gets rid of the symptoms of the disease. With a partial method of treatment, tachycardia attacks lose their strength and occur much less frequently; also increases the effectiveness of the use of antiarrhythmic drugs.

There are two types of treatment used in surgery:

• Destruction of additional pathways or foci of heterotopic automatism. Surgical intervention is carried out using minimally invasive methods using mechanical, electrical, laser, chemical, cryogenic agents. This is the so-called closed operation, in which two types of catheters are used - diagnostic and therapeutic. They are introduced into the patient's body through the femoral or subclavian vein. A diagnostic catheter using a computer allows you to determine the exact zone of occurrence of tachycardia. And a therapeutic catheter is used to carry out the procedure for influencing the PNT zone.
• The most common is radiofrequency ablation. The term "ablation" means removal, but in this treatment procedure, cauterization of the zone that caused the tachycardia is used.
• Implantation of pacemakers of two types - artificial driver rhythm (pacemaker) and an implantable cardioverter-defibrillator. Pacemakers must function in advance established regimes- couple stimulation, "exciting" stimulation and so on. Devices are set to automatically turn on after the onset of an attack.

Surgery for paroxysmal supraventricular tachycardia

With the ineffectiveness of drug therapy for paroxysmal supraventricular tachycardia, surgery is prescribed. Also, with congenital malformations in the structure of the heart muscle and impaired cardiac conduction (for example, with Wolff-Parkinson-White syndrome), surgical intervention is used.

The classical method is the operation on open heart, the purpose of which is to interrupt the impulse conduction along additional paths. Relief of the symptoms of tachycardia is achieved by cutting or removing pathological sections of the conduction system. Surgical intervention is performed using cardiopulmonary bypass.

So, surgery for paroxysmal supraventricular tachycardia is indicated for the following symptoms:

1. The occurrence of ventricular fibrillation, even in a single case.
2. Paroxysms of atrial fibrillation, which are repeated many times.
3. Sustained attacks of tachycardia that cannot be stopped with the use of antiarrhythmic therapy.
4. Availability birth defects and anomalies in the development of the heart.
5. Intolerance to drugs that block an attack of tachycardia and maintain a satisfactory condition of the patient between attacks.
6. The occurrence of PNT attacks in children and adolescents, which greatly complicate their physical, psycho-emotional and social development.

Prevention of paroxysmal supraventricular tachycardia is carried out with the help of healthy lifestyle life, the correct regimen of the day and diet, which were described in detail in the section "Treatment of paroxysmal supraventricular tachycardia". A patient with PNT should avoid strong psycho-emotional and physical stress, lead a sparing lifestyle, in which movement and rest are evenly combined. It is also necessary to exclude factors provoking tachycardia - smoking, drinking alcohol, coffee, strong tea, and so on.

Timely diagnosis and the use of antiarrhythmic drugs are also among the methods primary prevention PNT. As well as the treatment of the underlying disease that causes attacks of paroxysms of the heart. The use of sedatives is also prophylactic in the event of paroxysmal supraventricular tachycardia. One of the means of preventing attacks of PNT is timely surgical intervention.

There are forms of paroxysmal supraventricular tachycardia that cannot be prevented. The essential form of PNT belongs to this case, since the causes of its occurrence are still not known.

When making forecasts, it is necessary to take into account the causes and form of PNT. The frequency of occurrence and the duration of paroxysmal attacks, the presence or absence of complications, as well as the state of the myocardium are taken into account. For example, with severe damage to the heart muscle, acute heart or cardiovascular failure may occur. There is a high risk of ventricular fibrillation and ischemia with the affected myocardium; cases of unexpected death due to an attack of PNT have also been reported.

The effectiveness of the treatment of the underlying disease, as well as the rate of its progression, affect the condition of the patient with PNT.

The prognosis of the course of the disease in the essential form of paroxysmal supraventricular tachycardia is favorable, although its prevention is difficult due to the lack of identified causes of the disease. Patients with PNT may be able to work and retain active image life span of several years or decades. Rarely, there are also cases of sudden cure of PNT.

Paroxysmal supraventricular tachycardia can slow down its course with timely diagnosis and prevention of this disease.