HK-IN-PACE

Heart Rhythm Refresher Course

Module 2 - SVT: ECG, EPS and Ablation
18th August 2013

ECG for SVT Made Easy

Dr. K Chan
Ruttonjee and TSK Hospitals

SVT - Systematic Approach

(1) Relative position of the P wave & R-R interval
(2) Mode of initiation
(3) Mode of termination
(4) Morphology of the P wave
(5) Morphology of QRS
(6) Variation of cycle length
(6) Effect of AVB and BBB on the tachycardia
(7) Response to Valsalver Maneuver/ AVN blocker

SVT - Systematic Approach

(1) Relative position of the P wave & R-R interval
(2) Mode of initiation
(3) Mode of termination
(4) Morphology of the P wave
(5) Morphology of QRS
(6) Variation of cycle length
(6) Effect of AVB and BBB on the tachycardia
(7) Response to Valsalver Maneuver/ AVN blocker

PR and RP Timing
RP Time from ventricular activation
to subsequent atrial activation
Atrium
RP

PR

Ventricle
PR Time from atrial activation
to subsequent ventricular activation

PR-RP Relationship Typical AVNRT

Atrium

Retrograde FP
RP
PR

RP

PR
SP
RP
FP

PR

Slow
pathway

Fast
pathway

Antegrade SP
Ventricle

PR-RP Relationship - AVRT

Retrograde AP
RP
RP
AVN

AP
RP
AP
PR

PR
Antegrade AVN

PR

AVN

PR-RP Relationship - AT
RP = Time from R to next P
Not retrograde P

RP

RP
PR

PR
PR

Relative position of P wave within

the RR interval in SVT

Relative position of P wave within

the RR interval
Long RP Tachycardia (R-to-P interval > P-to-R interval)
Atrial Tachycardia
AVRT with slow-conducting retrograde AP
Permanent junctional reentry tachcycardia PJRT

Atypical AVNRT (Fast-slow AVNRT)

Sinus tachycardia/ Sinoatrial re-entry tachycardia
Short RP Tachycardia (R-to-P interval < R-to-P interval)
(> 90% Typical Slow-fast AVNRT & 87% AVRT, but only 11% AT
Short RP)
Typical AVNRT (Slow-fast AVNRT) ) ( RP <70ms)
When P waves coincides with QRS
no discernable P waves
Junctional ectopic tachycardia (JET)
AVRT (RP > 70ms)
AT

Kalbfleisch SJ et al. JACC 1993;21(1):85-89

Short RP Tachycardia
Typical AVNRT (slow-fast)
Retrograde via fast pathway Short RP

Short RP simultaneous activation of A and V

P waves hidden in QRS complexes
RP < 70ms

BMJ Vol 324; 16 Mar 2002

Short RP Tachyardia
Orthodromic AVRT

Short RP (RP >70ms):

Retrograde
via accessory pathway

PR: Antegrade via AVN

BMJ Vol 324; 16 Mar 2002

Long RP Tachycardia
Atypical AVNRT (Fast-Slow) AVNRT
Retrograde via slow
Pathway
Long RP
Long RP
SP

Short PR
Antegrade via Fast Pathway

Short RP

BMJ Vol 324; 16 Mar 2002

FP

Long RP Tachycardia
PJRT Permanent junctional
reciprocating tachycardia
Long RP

AVRT Retrograde accessory pathway with slow conducting property

Long R-P; -ve P in inferior leads; +ve P in lead aVL

Europace (2006) 8, 2128

SVT - Systematic Approach

(1) Relative position of the P wave & R-R interval
(2) Mode of initiation
(3) Mode of termination
(4) Morphology of the P wave
(5) Morphology of QRS
(6) Variation of cycle length
(6) Effect of AVB and BBB on the tachycardia
(7) Response to Valsalver Maneuver/ AVN blocker

Mode of initiation
Gradual onset/ warming up
Sinus tachycardia
Junctional ectopic tachycardia (JET)

Sudden onset
AT
AVNRT
AVRT
SART

Mode of Initiation
Assess any change of:
PR interval
PR Jump in typical slow-fast AVNRT

QRS complex morphology

Orthodromic AVRT Loss of pre-excitation

Variation of atrial cycle length & P wave

morphology
Atrial Tachycardia

Mode of Initiation of
Typical Slow-Fast AVNRT
Baseline Antegrade
Via Fast Pathway
PR Short

Antegrade block of
Fast pathway
Conducting via SP
PR prolongs

SP

SP

FP

PR Jump

FP

AVNRT initiates
Antegrade via SP
Retrograde via FP

SP

FP

Mode of Initiation
PR Jump Typical AVNRT

Initiation with a prolongation of PR interval (ie, a jump in the PR

interval)
Dependence on anterograde slow-pathway conduction of the
AV node to the ventricle (suggestive of slow fast AVNRT)
Antegrade conduction via SP

FP

FP

SP

Antegrade block of FP

Antegrade conduction via SP

PR Jump upon initiation of typical slow-fast AVNRT
Short RP Retrograde via Fast Pathway (VA or RP < 70ms)
Long PR Antegrade via Slow Pathway

Mode of Initiation Typical AVNRT

PR Jump

Prolongation of PR @ SVT initiation

Mode of Initiation - AVRT

In NSR, simultaneous
Activation of ventricle
via
Both AVN and AP

Antegrade block in AP
Antegrade conduction
Via AVN
Retrograde
activation via AP

Orthodromic AVRT
Antegrade via AVN
Retrograde via AP

Mode of initiation
Change of QRS morphology - AVRT
Atrial pacing with pre-excitation

Antegrade block of AP
loss of pre-excitation

Antegrade conduction only via AP
Initiation AVRT

Mode of Initiation - AT
Sinus P

P wave morphology changes in AT

1. Spontanousl variation of atrial cycle length before initiation of tachcyardia

2. Absence of definite PR jump
3. Subtle change of P wave morphology

Mode of initiation AT
Onset of tachycardia with change of
P wave morphologies

H Wellens. EHJ 1996(17). Supp C

SVT - Systematic Approach

(1) Relative position of the P wave & R-R interval
(2) Mode of initiation
(3) Mode of termination
(4) Morphology of the P wave
(5) Morphology of QRS
(6) Variation of cycle length
(6) Effect of AVB and BBB on the tachycardia
(7) Response to Valsalver Maneuver/ AVN blocker

Mode of termination
Spontaneous Termination with a P wave
Unlikely AT (In which case the last atrial beat
before termination have to coincide with AVB)
Spontaneous Termination with a QRS complex
Not helpful in differentiation

Mode of termination AVNRT vs AT

Termination with V

Termination with V
For AT to terminate with A
AT termination has to coincide with
simultaneous spontaneous AVB,
Which is unlikely

Mode of termination

Could be AVRT or AVNRT

Unlikely AT

SVT - Systematic Approach

(1) Relative position of the P wave & R-R interval
(2) Mode of initiation
(3) Mode of termination
(4) Morphology of P waves
(5) Morphology of QRS
(6) Variation of cycle length
(6) Effect of AVB and BBB on the tachycardia
(7) Response to Valsalver Maneuver/ AVN blocker

Morphologies of P waves
Compare morphologies of P waves in SR with
that in SVT
Pseudodelta waves
AVNRT

Look at P waves morphology/axis in:

Inferior leads
Lead V1
Lead aVL

Morphologies of P waves

Pseudo R waves in Typical AVNRT

Morphologies of P waves
Negative P waves in inferior leads:
Retrograde P (AVNRT, AVRT)
Ectopic atrial focus (AT)

Atrial Tachycardia

AVRT (PJRT)

Morphology of P waves
P waves in lead aVL
Positive or biphasic (negative-positive) : Right Atrial Focus (Right to left
activation)
Right Atrial Tachycardia
Activation towards left
aVL +ve

aV
L

LA
RA

Morphology of P waves
P waves in lead aVL
Negative or isoelectric: Left atrial focus
RA Atrial Tachycardia
Activation away from left

aVL ve

aV
L

LA
RA

Morphology of P waves
P waves in V1
Positive (Posterior to anterior/ left-to-right activation): Left atrial focus
Negative or biphasic (anterior to posterior/ right-to-left activation): Right
atrial focus

V2

V1

RA

LA

Postive P in V1
Left atrial focus

Negative
biphasic P in V1
Right atrial focus

Morphology of P waves
P waves in inferior leads
Positive (Hight to low activation): HRA/ High LA
Negative (Low to high activation): Retrograde P in AVNRT, AVRT or AT
with low atrial focus (e.g. CS/ low CT)
Postive inferior
leads
High
atrial focus
s
LA
RA

II

III

aVF

Negative inf
leads
Low
atrial focus

Morphology of P waves
Reverse Typical (Clockwise) Atrial Flutter

Reverse Typical A Flutter:

Positive P waves in II/III/aVF
Biphasic F wave in I, aVL, V1
Upright F wave in V6

Morphologies of P waves
Typical (counterclockwise) Atrial Flutter

Flutter waves ve
in inferior leads &
V6 & +ve in V1

Marc Gertsch. The ECG Manual An Evidence Baseed Approach. 2009.

Morphologies of P waves
Intra-atrial reentrant tachycardia

Intra-atrial reentrant tachycardia

(IART)

Macro-reentry over atrial scar

Morphologies of P waves MAT

Multifocal Atrial Tachcyardia

MAT Diagnosis:
1.>=3 P wave morphologies
2.Variable P-P Intervals
3.Iso-electric line beteween P waves

BMJ Vol 324; 9 Mar 2002

SVT - Systematic Approach

(1) Relative position of the P wave & R-R interval
(2) Mode of initiation
(3) Mode of termination
(4) Morphology of the P wave
(5) Morphology of QRS
(6) Variation of cycle length
(6) Effect of AVB and BBB on the tachycardia
(7) Response to Valsalver Maneuver/ AVN blocker

Morhpologies of QRS
Narrow complexes
AT
AVNRT/JET
AVRT

Wide complexes
Antidromic AVRT (Pre-excitation)
SVT with BBB
VT?

R < 30ms
No S notching

Unless the QRS morphologies in V1 & V6 are absolutely typical of BBB,

preexcited AF will be diagnosed
Sensitivity of 100%. Specificity of 85% (29/34) in diagnosing pre-excited AF
Ernest W PACE Dec 2003

QRS Morphology AT with RBBB

AV Reentrant Tachycardia
Orthodromic AVRT

Antidromic AVRT
Antegrade
via AP

Retrograde
Via AP

Antegrade
via AVN
Retrograde
Via AVN

QRS Morphology
Antidromic AVRT

QRS Morphology Orthodromic AVRT

QRS Morphology
WPW AP Localisation

WPW AP Localisation

WPW AP Localisation

SVT - Systematic Approach

(1) Relative position of the P wave & R-R interval
(2) Mode of initiation
(3) Mode of termination
(4) Morphology of the P wave
(5) Morphology of QRS
(6) Variation of cycle length
(6) Effect of AVB and BBB on the tachycardia
(7) Response to Valsalver Maneuver/ AVN blocker

Variation of Cycle Length

Variation of cycle length and QRS alternans can occur in
AVRT with multiple accessory pathway
Atrial tachycardia
AVNRT with > multiple slow/fast pathways
AVRT with coexisting dual AVN physiology
Change in P-P interval preceding change in V-V interval

Less useful for diagnosis (usually AT, but can be AVNRT or AVRT)
Change in R-R interval preceding change in P-P interval

Unlikely AT

Variation of cycle length

Atrial tachycardia with spontaneous variation in cycle length

Orthodromic AVRT with alternating conduction via fast and slow pathway

AVNRT with cycle length & QRS alternans due to 3 nodal pathways

QRS Alternans
QRS alternans - Phasic alternation of QRS amplitude
Most commonly in AVRT
25-38% of orthodromic AVRT
13-23% of AVNRT , but virtually never seen in AT

Aleksander Bardyszewski et al. Kardiol Pol 2006; 64: 649-651

Green M et al. Circulation. 1983;68(2):368-373.
Morady F. Pacing Clin Electrophysiol. 1991;14(12):2193-2198.
Kay GN. Am J Cardiol. 1987;59(4):296-300.
Kalbfleisch SJ et al. JACC 1993;21(1):85-89

SVT - Systematic Approach

(1) Relative position of the P wave & R-R interval
(2) Mode of initiation
(3) Mode of termination
(4) Morphology of the P wave
(5) Morphology of QRS
(6) Variation of cycle length
(6) Effect of AVB and BBB on the tachycardia
(7) Response to Valsalver Maneuver/ AVN blocker

AV Block During Tachycardia

Carotid Sinus Massage causing AV Block
reveals underlying atrial flutter

AV Block during tachcyardia

Continuation of tachycardia with AVB rules out AVRT

Atrial Tachycardia 1:1 Conduction

Atrial Tachycardia 2:1 Conduction

Effect of intermittent BBB during SVT

Prolongation of tachycardia cycle length and V to A time with bundle
branch block
Suggests the bundle branch is part of the tachycardia circuit
AVRT with Accessory Pathway on the same side of the bundle branch
block
Bundle Branch Block with no effect on tachycardia cycle length / V to A
time
Suggests the bundle branch is not integral part of the tachycardia
circuit
AVRT with accessory pathway contralateral to the bundle branch block
AT
AVNRT
Coumel P. Eur J Cardiol. 1974;1(4):423-436.

Effect of Bundle Branch Block

AVRT - Ipsilateral BBB

Prolongs TCL and VA
Ipsilateral bundle branch block (LBBB) in AVRT using left side AP

LBBB

LBBB
Prolongs conduction time
prolongs tachycardia cycle lenth & V to A time

AVRT - Contralateral BBB

No change in TCL & VA

RBBB

Conduction block in the contralateral bundle (RBBB) does not affect

The tachycardia cycle length and VA conduction time, as it is not involved
In the tachycardia circuit

SVT - Systematic Approach

(1) Relative position of the P wave & R-R interval
(2) Mode of initiation
(3) Mode of termination
(4) Morphology of the P wave
(5) Morphology of QRS
(6) Variation of cycle length
(6) Effect of AVB and BBB on the tachycardia
(7) Response to Valsalver Maneuver/ AVN blocker

Response to Adenosine
Atrial Tachycardia
AV Block with continuation of atrial tachcyardia

Adenosine
Tachycardia continuation with AV block
suggest ventricle is not an integral
Part of the tachycardia circuit
Rules out AVRT

SVT - Systematic Approach

(1) Relative position of the P wave & R-R interval
(2) Mode of initiation
(3) Mode of termination
(4) Morphology of the P wave
(5) Morphology of QRS
(6) Variation of cycle length
(6) Effect of AVB and BBB on the tachycardia
(7) Response to Valsalver Maneuver/ AVN blocker

References
1. Josephson ME and Wellens HJ. Differential diagnosis of supraventricular
tachycardia. Cardiol Clin 1990;8(3): 411-42
2. Wellens HJJ et al. The ECG in Emergency Decision Making. Ed 2. Philadelphia,
Saunders 2005.
3. Wellens HJJ. The value of the ECG in the diagnosis of supraventricular tachycardias.
European Heart Journal. 1996;17 Supp C:10-20
4. David J Fox. Supraventricular tachycardia: Diagnosis and Management. Mayo Clin
Proc 2008;83(12): 1400-1411
5. Uday N Kuma et al. The 12 Lead Electrocardiogram in Supraventricular Tachycardia.
Cardiol Clin 2006;24: 427-437
6. Daneil Frisch. Supraventricular Tachycardia Presentation Slides Thomas Jefferson
University Hospital
7. Francis Murgatroyd et al. Handbook of cardiac electrophysiology.