Atrioventricular Nodal Re-entry Tachycardia (AVNRT) is a type of supraventricular tachycardia characterized by a rapid heart rate originating in the atrioventricular (AV) node of the heart. The AV node is a crucial part of the heart’s electrical conduction system.
It is responsible for coordinating the electrical signals between the atria and the ventricles. In AVNRT, there is a re-entry circuit within or near the AV node, leading to a rapid and regular heartbeat. This abnormal circuit causes the electrical signals to circulate in a loop within the AV node, resulting in the rapid firing of the heart.
Epidemiology
Globally, the prevalence of atrioventricular nodal re-entry tachycardia (AVNRT) closely mirrors that in the United States. Nearly 60% of cases of paroxysmal supraventricular tachycardia are attributed to AVNRT, and about two-thirds of these cases occur in women.
According to a study, most individuals experiencing symptomatic AVNRT are in their twenties; however, there are instances where patients may present with AVNRT in their seventh or eighth decade of life.
Anatomy
Pathophysiology
The AV node has two distinct pathways known as the slow pathway and the fast pathway. The fast pathway allows for rapid conduction of electrical impulses, while the slow pathway conducts signals more slowly. AVNRT typically occurs when there is a unidirectional block in one of the pathways. This means that electrical impulses can travel down one pathway but face a barrier when attempting to travel back up the same pathway.
The unidirectional block creates conditions favorable for the formation of a re-entry circuit. During normal conduction, electrical signals pass through the AV node and continue their journey through the heart. In AVNRT, an electrical impulse may travel down the fast pathway, encounter blockage when attempting to travel back up the slow pathway, and then circulate back up the fast pathway in a loop.
This looping of electrical signals within or near the AV node results in a rapid, regular heartbeat characteristic of AVNRT. AVNRT often has a sudden onset and can be triggered by various factors such as stress, caffeine, or other stimulants. Episodes can also terminate abruptly, especially with interventions like vagal maneuvers (e.g., the Valsalva maneuver) or medications.
Etiology
Age and Gender:
AVNRT can occur at any age, but there may be variations in its prevalence among different age groups. Studies have shown that most patients presenting with AVNRT symptoms are in their twenties, but it can also be diagnosed in individuals in their seventh or eighth decade of life. There is a higher incidence of AVNRT in women, with approximately two-thirds of cases occurring in females.
Genetic Predisposition:
While AVNRT is often acquired and related to the anatomy and electrophysiology of the AV node, there may be a genetic component in some cases. Some individuals may have a genetic predisposition that influences the development of the dual pathways or the susceptibility to re-entry circuits.
Triggering Factors:
Various factors, including stress, caffeine, tobacco use, and certain medications, can trigger AVNRT episodes. These triggering factors may influence the excitability of the AV node and contribute to the initiation of re-entry circuits.
Genetics
Prognostic Factors
Clinical History
Patients with Atrioventricular Nodal Reentry Tachycardia (AVNRT) often present with a history of recurrent, sudden-onset episodes of rapid heartbeat. Patients may report palpitations, a fluttering sensation in the chest, dizziness, lightheadedness, and, in some cases, syncope. Rapid heart rate and associated symptoms can cause fatigue and a general sense of weakness.
The sudden onset of palpitations and other symptoms may contribute to anxiety. AVNRT episodes often have a sudden and unexpected onset. Episodes may terminate abruptly, especially with interventions like vagal maneuvers (e.g., Valsalva maneuver) or medications.
Physical Examination
During episodes, a physical examination may reveal a rapid and regular pulse. Blood pressure may be within normal limits, although it can be variable within the range of 140 to 280 bpm. Hypotension resulting from diminished ventricular filling can also emerge as a notable observation during the physical examination of individuals presenting with atrioventricular nodal re-entry tachycardia.
An ECG is the primary diagnostic tool, revealing a narrow-complex tachycardia with characteristic features during AVNRT episodes. An event monitor is another tool that patients can use to record ECG tracings during symptomatic episodes. A Holter monitor may be used for longer-term monitoring to capture episodes that may not be evident during a brief clinic visit.
Age group
Associated comorbidity
Associated activity
Acuity of presentation
Differential Diagnoses
Atrial flutter
Atrial tachycardia
Sinus tachycardia
Junctional ectopic tachycardia
Intra-atrial re-entrant tachycardia
Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
Staging
Treatment Paradigm
The treatment paradigm for Atrioventricular Nodal Re-entry Tachycardia (AVNRT) involves a multi-faceted approach tailored to the individual patient’s clinical presentation. In acute settings, hemodynamically unstable patients exhibiting symptoms such as hypotension, ischemic chest pain, altered mental status, respiratory failure, or shock require urgent electrical cardioversion for immediate termination of the tachycardia.
For hemodynamically stable patients, the initial step involves attempting vagal maneuvers to acutely cease the rhythm. If unsuccessful after two attempts, modified vagal exercises can be employed at least twice. In cases where such maneuvers prove ineffective or are inappropriate, intravenous (IV) medical therapy is warranted.
Adenosine, with its transient but potent inhibitory effect on the atrioventricular (AV) node, is commonly used for acute termination due to its rapid onset of action.Additionally, intravenous non-dihydropyridine calcium channel blockers, such as verapamil or diltiazem, are employed to slow conduction through the AV node and terminate the reentry circuit.
However, long-term management often involves catheter ablation. This highly effective and safe procedure selectively eliminates the abnormal pathway responsible for AVNRT, offering a potential cure and reducing the recurrence of tachycardia episodes. This comprehensive approach aims to address both acute symptoms and provide a sustainable solution for the chronic management of AVNRT.
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Adenosine
Adenosine plays a crucial role in the treatment of AVNRT. Adenosine is commonly used as a medication to help terminate AVNRT episodes. Adenosine is administered rapidly via intravenous (IV) bolus. The medication is usually given in a dose of 6-12 mg, followed by a saline flush to ensure quick delivery to the heart.
Patients receiving adenosine should be closely monitored for potential side effects, including transient chest discomfort, flushing, and shortness of breath. Adenosine is generally contraindicated in patients with certain pre-existing conditions, such as severe asthma, as it may exacerbate bronchoconstriction.
Digoxin has a slower onset of action compared to medications like adenosine, which are commonly used for acute termination of AVNRT. Its effects may take time to manifest, making it less suitable for rapidly terminating the tachycardia during an acute episode.
While digoxin is not a preferred choice for terminating AVNRT acutely, it may be considered in some cases for long-term rate control in patients with recurrent AVNRT or other atrial arrhythmias.
It is more commonly used in conditions like atrial fibrillation with rapid ventricular response. Caution is advised when using digoxin in patients with impaired renal function, as digoxin is primarily excreted through the kidneys. Digoxin levels should be monitored carefully to avoid toxicity.
Calcium Channel Blockers
Verapamil and diltiazem are often used for the acute termination of AVNRT episodes. Their rapid onset of action makes them suitable for converting the heart rhythm to normal sinus rhythm during an acute episode.
These medications are administered intravenously in a controlled manner to achieve the desired effect. The dosage is carefully titrated to balance the need for termination of AVNRT with the potential side effects, such as hypotension.
While non-dihydropyridine calcium channel blockers are effective for acute termination, they are not typically used for long-term maintenance therapy for AVNRT. Catheter ablation is often considered for patients requiring ongoing management.
intervention-with-procedure
Valsalva maneuver
Patients who are hemodynamically unstable may present with tachycardia accompanied by hypotension, ischemic chest pain, altered mental status, respiratory failure, or shock.
For these individuals, prompt electrical cardioversion is necessary to terminate the Atrioventricular Nodal Re-entry Tachycardia (AVNRT). In contrast, hemodynamically stable patients should initially undergo vagal maneuvers in an attempt to cease the rhythm acutely.
If these maneuvers are ineffective after two attempts and the patient remains in AVNRT, clinicians should then perform modified vagal exercises at least twice to terminate the arrhythmia. In cases where such maneuvers prove unsuccessful or are deemed inappropriate, intravenous medical therapy becomes warranted.
Catheter Ablation
Catheter ablation for AVNRT has high success rates, with a significant reduction in the recurrence of tachycardia episodes. Successful ablation results in a normalization of the heart’s electrical conduction system, preventing the reentrant circuit from causing rapid heart rates.
Patients are typically monitored for a short period after the procedure to ensure stability and to detect any potential complications. Most patients experience a significant improvement in symptoms following successful catheter ablation.
»
Home » CAD » Atrioventricular Nodal Re-entry Tachycardia
Atrioventricular Nodal Re-entry Tachycardia
Updated :
December 8, 2023
Atrioventricular Nodal Re-entry Tachycardia (AVNRT) is a type of supraventricular tachycardia characterized by a rapid heart rate originating in the atrioventricular (AV) node of the heart. The AV node is a crucial part of the heart’s electrical conduction system.
It is responsible for coordinating the electrical signals between the atria and the ventricles. In AVNRT, there is a re-entry circuit within or near the AV node, leading to a rapid and regular heartbeat. This abnormal circuit causes the electrical signals to circulate in a loop within the AV node, resulting in the rapid firing of the heart.
Globally, the prevalence of atrioventricular nodal re-entry tachycardia (AVNRT) closely mirrors that in the United States. Nearly 60% of cases of paroxysmal supraventricular tachycardia are attributed to AVNRT, and about two-thirds of these cases occur in women.
According to a study, most individuals experiencing symptomatic AVNRT are in their twenties; however, there are instances where patients may present with AVNRT in their seventh or eighth decade of life.
The AV node has two distinct pathways known as the slow pathway and the fast pathway. The fast pathway allows for rapid conduction of electrical impulses, while the slow pathway conducts signals more slowly. AVNRT typically occurs when there is a unidirectional block in one of the pathways. This means that electrical impulses can travel down one pathway but face a barrier when attempting to travel back up the same pathway.
The unidirectional block creates conditions favorable for the formation of a re-entry circuit. During normal conduction, electrical signals pass through the AV node and continue their journey through the heart. In AVNRT, an electrical impulse may travel down the fast pathway, encounter blockage when attempting to travel back up the slow pathway, and then circulate back up the fast pathway in a loop.
This looping of electrical signals within or near the AV node results in a rapid, regular heartbeat characteristic of AVNRT. AVNRT often has a sudden onset and can be triggered by various factors such as stress, caffeine, or other stimulants. Episodes can also terminate abruptly, especially with interventions like vagal maneuvers (e.g., the Valsalva maneuver) or medications.
Age and Gender:
AVNRT can occur at any age, but there may be variations in its prevalence among different age groups. Studies have shown that most patients presenting with AVNRT symptoms are in their twenties, but it can also be diagnosed in individuals in their seventh or eighth decade of life. There is a higher incidence of AVNRT in women, with approximately two-thirds of cases occurring in females.
Genetic Predisposition:
While AVNRT is often acquired and related to the anatomy and electrophysiology of the AV node, there may be a genetic component in some cases. Some individuals may have a genetic predisposition that influences the development of the dual pathways or the susceptibility to re-entry circuits.
Triggering Factors:
Various factors, including stress, caffeine, tobacco use, and certain medications, can trigger AVNRT episodes. These triggering factors may influence the excitability of the AV node and contribute to the initiation of re-entry circuits.
Patients with Atrioventricular Nodal Reentry Tachycardia (AVNRT) often present with a history of recurrent, sudden-onset episodes of rapid heartbeat. Patients may report palpitations, a fluttering sensation in the chest, dizziness, lightheadedness, and, in some cases, syncope. Rapid heart rate and associated symptoms can cause fatigue and a general sense of weakness.
The sudden onset of palpitations and other symptoms may contribute to anxiety. AVNRT episodes often have a sudden and unexpected onset. Episodes may terminate abruptly, especially with interventions like vagal maneuvers (e.g., Valsalva maneuver) or medications.
During episodes, a physical examination may reveal a rapid and regular pulse. Blood pressure may be within normal limits, although it can be variable within the range of 140 to 280 bpm. Hypotension resulting from diminished ventricular filling can also emerge as a notable observation during the physical examination of individuals presenting with atrioventricular nodal re-entry tachycardia.
An ECG is the primary diagnostic tool, revealing a narrow-complex tachycardia with characteristic features during AVNRT episodes. An event monitor is another tool that patients can use to record ECG tracings during symptomatic episodes. A Holter monitor may be used for longer-term monitoring to capture episodes that may not be evident during a brief clinic visit.
Atrial flutter
Atrial tachycardia
Sinus tachycardia
Junctional ectopic tachycardia
Intra-atrial re-entrant tachycardia
The treatment paradigm for Atrioventricular Nodal Re-entry Tachycardia (AVNRT) involves a multi-faceted approach tailored to the individual patient’s clinical presentation. In acute settings, hemodynamically unstable patients exhibiting symptoms such as hypotension, ischemic chest pain, altered mental status, respiratory failure, or shock require urgent electrical cardioversion for immediate termination of the tachycardia.
For hemodynamically stable patients, the initial step involves attempting vagal maneuvers to acutely cease the rhythm. If unsuccessful after two attempts, modified vagal exercises can be employed at least twice. In cases where such maneuvers prove ineffective or are inappropriate, intravenous (IV) medical therapy is warranted.
Adenosine, with its transient but potent inhibitory effect on the atrioventricular (AV) node, is commonly used for acute termination due to its rapid onset of action.Additionally, intravenous non-dihydropyridine calcium channel blockers, such as verapamil or diltiazem, are employed to slow conduction through the AV node and terminate the reentry circuit.
However, long-term management often involves catheter ablation. This highly effective and safe procedure selectively eliminates the abnormal pathway responsible for AVNRT, offering a potential cure and reducing the recurrence of tachycardia episodes. This comprehensive approach aims to address both acute symptoms and provide a sustainable solution for the chronic management of AVNRT.
Adenosine
Adenosine plays a crucial role in the treatment of AVNRT. Adenosine is commonly used as a medication to help terminate AVNRT episodes. Adenosine is administered rapidly via intravenous (IV) bolus. The medication is usually given in a dose of 6-12 mg, followed by a saline flush to ensure quick delivery to the heart.
Patients receiving adenosine should be closely monitored for potential side effects, including transient chest discomfort, flushing, and shortness of breath. Adenosine is generally contraindicated in patients with certain pre-existing conditions, such as severe asthma, as it may exacerbate bronchoconstriction.
Digoxin has a slower onset of action compared to medications like adenosine, which are commonly used for acute termination of AVNRT. Its effects may take time to manifest, making it less suitable for rapidly terminating the tachycardia during an acute episode.
While digoxin is not a preferred choice for terminating AVNRT acutely, it may be considered in some cases for long-term rate control in patients with recurrent AVNRT or other atrial arrhythmias.
It is more commonly used in conditions like atrial fibrillation with rapid ventricular response. Caution is advised when using digoxin in patients with impaired renal function, as digoxin is primarily excreted through the kidneys. Digoxin levels should be monitored carefully to avoid toxicity.
Calcium Channel Blockers
Verapamil and diltiazem are often used for the acute termination of AVNRT episodes. Their rapid onset of action makes them suitable for converting the heart rhythm to normal sinus rhythm during an acute episode.
These medications are administered intravenously in a controlled manner to achieve the desired effect. The dosage is carefully titrated to balance the need for termination of AVNRT with the potential side effects, such as hypotension.
While non-dihydropyridine calcium channel blockers are effective for acute termination, they are not typically used for long-term maintenance therapy for AVNRT. Catheter ablation is often considered for patients requiring ongoing management.
Valsalva maneuver
Patients who are hemodynamically unstable may present with tachycardia accompanied by hypotension, ischemic chest pain, altered mental status, respiratory failure, or shock.
For these individuals, prompt electrical cardioversion is necessary to terminate the Atrioventricular Nodal Re-entry Tachycardia (AVNRT). In contrast, hemodynamically stable patients should initially undergo vagal maneuvers in an attempt to cease the rhythm acutely.
If these maneuvers are ineffective after two attempts and the patient remains in AVNRT, clinicians should then perform modified vagal exercises at least twice to terminate the arrhythmia. In cases where such maneuvers prove unsuccessful or are deemed inappropriate, intravenous medical therapy becomes warranted.
Catheter Ablation
Catheter ablation for AVNRT has high success rates, with a significant reduction in the recurrence of tachycardia episodes. Successful ablation results in a normalization of the heart’s electrical conduction system, preventing the reentrant circuit from causing rapid heart rates.
Patients are typically monitored for a short period after the procedure to ensure stability and to detect any potential complications. Most patients experience a significant improvement in symptoms following successful catheter ablation.
medtigo
Atrioventricular Nodal Re-entry Tachycardia
Updated :
December 8, 2023
Atrioventricular Nodal Re-entry Tachycardia (AVNRT) is a type of supraventricular tachycardia characterized by a rapid heart rate originating in the atrioventricular (AV) node of the heart. The AV node is a crucial part of the heart’s electrical conduction system.
It is responsible for coordinating the electrical signals between the atria and the ventricles. In AVNRT, there is a re-entry circuit within or near the AV node, leading to a rapid and regular heartbeat. This abnormal circuit causes the electrical signals to circulate in a loop within the AV node, resulting in the rapid firing of the heart.
Globally, the prevalence of atrioventricular nodal re-entry tachycardia (AVNRT) closely mirrors that in the United States. Nearly 60% of cases of paroxysmal supraventricular tachycardia are attributed to AVNRT, and about two-thirds of these cases occur in women.
According to a study, most individuals experiencing symptomatic AVNRT are in their twenties; however, there are instances where patients may present with AVNRT in their seventh or eighth decade of life.
The AV node has two distinct pathways known as the slow pathway and the fast pathway. The fast pathway allows for rapid conduction of electrical impulses, while the slow pathway conducts signals more slowly. AVNRT typically occurs when there is a unidirectional block in one of the pathways. This means that electrical impulses can travel down one pathway but face a barrier when attempting to travel back up the same pathway.
The unidirectional block creates conditions favorable for the formation of a re-entry circuit. During normal conduction, electrical signals pass through the AV node and continue their journey through the heart. In AVNRT, an electrical impulse may travel down the fast pathway, encounter blockage when attempting to travel back up the slow pathway, and then circulate back up the fast pathway in a loop.
This looping of electrical signals within or near the AV node results in a rapid, regular heartbeat characteristic of AVNRT. AVNRT often has a sudden onset and can be triggered by various factors such as stress, caffeine, or other stimulants. Episodes can also terminate abruptly, especially with interventions like vagal maneuvers (e.g., the Valsalva maneuver) or medications.
Age and Gender:
AVNRT can occur at any age, but there may be variations in its prevalence among different age groups. Studies have shown that most patients presenting with AVNRT symptoms are in their twenties, but it can also be diagnosed in individuals in their seventh or eighth decade of life. There is a higher incidence of AVNRT in women, with approximately two-thirds of cases occurring in females.
Genetic Predisposition:
While AVNRT is often acquired and related to the anatomy and electrophysiology of the AV node, there may be a genetic component in some cases. Some individuals may have a genetic predisposition that influences the development of the dual pathways or the susceptibility to re-entry circuits.
Triggering Factors:
Various factors, including stress, caffeine, tobacco use, and certain medications, can trigger AVNRT episodes. These triggering factors may influence the excitability of the AV node and contribute to the initiation of re-entry circuits.
Patients with Atrioventricular Nodal Reentry Tachycardia (AVNRT) often present with a history of recurrent, sudden-onset episodes of rapid heartbeat. Patients may report palpitations, a fluttering sensation in the chest, dizziness, lightheadedness, and, in some cases, syncope. Rapid heart rate and associated symptoms can cause fatigue and a general sense of weakness.
The sudden onset of palpitations and other symptoms may contribute to anxiety. AVNRT episodes often have a sudden and unexpected onset. Episodes may terminate abruptly, especially with interventions like vagal maneuvers (e.g., Valsalva maneuver) or medications.
During episodes, a physical examination may reveal a rapid and regular pulse. Blood pressure may be within normal limits, although it can be variable within the range of 140 to 280 bpm. Hypotension resulting from diminished ventricular filling can also emerge as a notable observation during the physical examination of individuals presenting with atrioventricular nodal re-entry tachycardia.
An ECG is the primary diagnostic tool, revealing a narrow-complex tachycardia with characteristic features during AVNRT episodes. An event monitor is another tool that patients can use to record ECG tracings during symptomatic episodes. A Holter monitor may be used for longer-term monitoring to capture episodes that may not be evident during a brief clinic visit.
Atrial flutter
Atrial tachycardia
Sinus tachycardia
Junctional ectopic tachycardia
Intra-atrial re-entrant tachycardia
The treatment paradigm for Atrioventricular Nodal Re-entry Tachycardia (AVNRT) involves a multi-faceted approach tailored to the individual patient’s clinical presentation. In acute settings, hemodynamically unstable patients exhibiting symptoms such as hypotension, ischemic chest pain, altered mental status, respiratory failure, or shock require urgent electrical cardioversion for immediate termination of the tachycardia.
For hemodynamically stable patients, the initial step involves attempting vagal maneuvers to acutely cease the rhythm. If unsuccessful after two attempts, modified vagal exercises can be employed at least twice. In cases where such maneuvers prove ineffective or are inappropriate, intravenous (IV) medical therapy is warranted.
Adenosine, with its transient but potent inhibitory effect on the atrioventricular (AV) node, is commonly used for acute termination due to its rapid onset of action.Additionally, intravenous non-dihydropyridine calcium channel blockers, such as verapamil or diltiazem, are employed to slow conduction through the AV node and terminate the reentry circuit.
However, long-term management often involves catheter ablation. This highly effective and safe procedure selectively eliminates the abnormal pathway responsible for AVNRT, offering a potential cure and reducing the recurrence of tachycardia episodes. This comprehensive approach aims to address both acute symptoms and provide a sustainable solution for the chronic management of AVNRT.
Adenosine
Adenosine plays a crucial role in the treatment of AVNRT. Adenosine is commonly used as a medication to help terminate AVNRT episodes. Adenosine is administered rapidly via intravenous (IV) bolus. The medication is usually given in a dose of 6-12 mg, followed by a saline flush to ensure quick delivery to the heart.
Patients receiving adenosine should be closely monitored for potential side effects, including transient chest discomfort, flushing, and shortness of breath. Adenosine is generally contraindicated in patients with certain pre-existing conditions, such as severe asthma, as it may exacerbate bronchoconstriction.
Digoxin has a slower onset of action compared to medications like adenosine, which are commonly used for acute termination of AVNRT. Its effects may take time to manifest, making it less suitable for rapidly terminating the tachycardia during an acute episode.
While digoxin is not a preferred choice for terminating AVNRT acutely, it may be considered in some cases for long-term rate control in patients with recurrent AVNRT or other atrial arrhythmias.
It is more commonly used in conditions like atrial fibrillation with rapid ventricular response. Caution is advised when using digoxin in patients with impaired renal function, as digoxin is primarily excreted through the kidneys. Digoxin levels should be monitored carefully to avoid toxicity.
Calcium Channel Blockers
Verapamil and diltiazem are often used for the acute termination of AVNRT episodes. Their rapid onset of action makes them suitable for converting the heart rhythm to normal sinus rhythm during an acute episode.
These medications are administered intravenously in a controlled manner to achieve the desired effect. The dosage is carefully titrated to balance the need for termination of AVNRT with the potential side effects, such as hypotension.
While non-dihydropyridine calcium channel blockers are effective for acute termination, they are not typically used for long-term maintenance therapy for AVNRT. Catheter ablation is often considered for patients requiring ongoing management.
Valsalva maneuver
Patients who are hemodynamically unstable may present with tachycardia accompanied by hypotension, ischemic chest pain, altered mental status, respiratory failure, or shock.
For these individuals, prompt electrical cardioversion is necessary to terminate the Atrioventricular Nodal Re-entry Tachycardia (AVNRT). In contrast, hemodynamically stable patients should initially undergo vagal maneuvers in an attempt to cease the rhythm acutely.
If these maneuvers are ineffective after two attempts and the patient remains in AVNRT, clinicians should then perform modified vagal exercises at least twice to terminate the arrhythmia. In cases where such maneuvers prove unsuccessful or are deemed inappropriate, intravenous medical therapy becomes warranted.
Catheter Ablation
Catheter ablation for AVNRT has high success rates, with a significant reduction in the recurrence of tachycardia episodes. Successful ablation results in a normalization of the heart’s electrical conduction system, preventing the reentrant circuit from causing rapid heart rates.
Patients are typically monitored for a short period after the procedure to ensure stability and to detect any potential complications. Most patients experience a significant improvement in symptoms following successful catheter ablation.
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