Paroxysmal

Supraventrikular
Tachycardias
Chintya & Citra

16-044 & 16-061

ATRIOVENTRICULAR
NODAL
REENTRY TACHYCARDI
A (AVNRT)
DEFINITION

Atrioventricular nodal reentry tachycardia (AVNRT)

is the most common type of reentrant
supraventricular tachycardia (SVT). The substrate
for AVNRT is the presence of dual AV nodal
pathways.

https://emedicine.medscape.com/article/160215-overview

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ETIOLOGY
A condition for AVNRT to occur is
that 2 electric pathways occur in
and around the AV node (a slow
paced and a fast paced pathway).
That gives way to the occurrence
of re-entry.

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EPIDEMIOLOG
Y
In the United States, AVNRT occurs in
60% of patients (with a female
predominance) presenting with paroxysmal
SVT. The ratio is approximately 3:1.
The prevalence of SVT in the general
population is likely several cases per
thousand persons.
Internationally, the occurrence of AVNRT is
similar to that in the United States.
AVNRT may occur in persons of any age. It
is common in young adults, but some
patients do not present until their seventh
or eighth decade or later.
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GEJALA KLINIS
Symptoms are bouts of fast heart
rates with sudden onset. Neck
vein palpitations can be
prominent (the 'Frog Sign').
An AVNRT is a regular rhythm
with a rate of 180-250 /min.

http://en.ecgpedia.org/wiki/AVNRT
emedicine.medscape.com 6

AVNRT is typically paroxysmal and may occur spontaneously in patients or upon provocation with
exertion, coffee, tea or alcohol. It is more common in women than men (~75% of cases occurring in
women) and may occur in young and healthy patients as well as those suffering chronic heart
disease.

Patients will typically complain of the sudden onset of rapid, regular palpitations. The patient may
experience a brief fall in blood pressure causing presyncope or occasionally syncope.

If the patient has underlying coronary artery disease the patient may experience chest pain similar
to angina (tight band around the chest radiating to left arm or left jaw).

The patient may complain of shortness of breath, anxiety and occasionally polyuria due to elevated
atrial pressure releasing atrial natriuretic peptide.

The tachycardia typically ranges between 140-280 bpm and is regular in nature. It may cease
spontaneously (and abruptly) or continue indefinitely until medical treatment is sought.

The condition is generally well tolerated and is rarely life threatening in patients with pre-existing
heart disease.
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TWO FORMS OF
AVNRT OCCUR:
TYPICAL AND
ATYPICAL AVNRT

Typical AVNRT Atypical ANVRT

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http://en.ecgpedia.org/wiki/AVNRT
Typical AVNRT (also described as common AVNRT or slow-fast AVNRT): The impulse travels over
the slow pathway towards the ventricles and returns via the fast pathway to the atria. The retrograde
P wave (or Atrial echo) shows up at the end of the QRS. 90 % of all patients with AVNRT are
diagnosed with typical AVNRT. Spontaneous termination of typical AVNRT often occurs in the fast
pathway (terminates with a QRS on the ECG), induced termination with carotid sinus massage or
adenosine results in termination in the slow pathway (terminates with retrograde P on ECG).

Atypical ANVRT (also described as uncommon AVNRT or fast-slow AVNRT): The impulse travels
via the fast pathway towards the ventricles and returns via the slow pathway to the atria. The
retrograde P wave appears far behind the QRS. Only about 6% of all ANVRT patients are diagnosed
with atypical AVNRT.

The remaining cases of AVNRT patients are diagnosed with a form of AVNRT that is even more
rare. This form of AVNRT is slow/slow AVNRT (The impulse follows a complex route through the AV
node and the surrounding area). Only 4 % of all patients diagnosed with AVNRT have slow/slow
AVNRT.

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http://en.ecgpedia.org/wiki/AVNRT
PATHOPHYSIOLOGY AND
TYPES OF AVNRT
AVNRT is caused by a reentry circuit in or around the AV
node.

The circuit is formed by the creation of two pathways forming

the re-entrant circuit, namely the slow and fast pathways.

The fast pathway is usually anteriorly situated along septal

portion of tricuspid annulus with the slow pathway
situated posteriorly, close to the coronary sinus ostium.

Sustained reentry occurs over a circuit comprising the AV

node, His Bundle, ventricle, accessory pathway and atrium.

The various forms of AVNRT can be described in terms of

ECG appearance such as R-P intervals or Slow/Fast pathway
dominance.
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 SLOW-FAST
AVNRT (COMMON
AVNRT)

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Accounts for 80-90% of AVNRT

Associated with Slow AV nodal pathway for anterograde conduction and Fast AV nodal pathway for
retrograde conduction.

The retrograde P wave is obscured in the corresponding QRS or occurs at the end of the QRS complex as
pseudo r or S waves

ECG:

P waves are often hidden being embedded in the QRS complexes.

Pseudo r wave may be seen in V1

Pseudo S waves may be seen in leads II, III or aVF.

In most cases this results in a typical SVT appearance with absent P waves and tachycardia

Cardiac rhythm strips demonstrating (top) sinus rhythm and (bottom) paroxysmal supraventricular
tachycardia. The P wave is seen as a pseudo-R wave (circled in bottom strip) in lead V1during tachycardia.
By contrast, the pseudo-R wave is not seen during sinus rhythm (it is absent from circled area in top strip).
This very short ventriculoatrial time is frequently seen in typical Slow-Fast Atrioventricular Nodal Reentrant
Tachycardia.
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FAST-SLOW
AVNRT (UNCOMMON
AVNRT)

Accounts for 10% of AVNRT

Associated with Fast AV nodal pathway for

anterograde conduction and Slow AV nodal pathway
for retrograde conduction.

The retrograde P wave appears after the

corresponding QRS

ECG

QRS -P-T complexes

P waves are visible between the QRS and T wave

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15
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 SLOW-SLOW
AVNRT (ATYPICAL
AVNRT)
*1-5% AVNRT

*Associated with Slow AV nodal pathway

for anterograde conduction and Slow left
atrial fibres approaching the AV node as
the pathway for retrograde conduction.

*ECG: Tachycardia with a P-wave seen in

mid-diastole effectively appearing before
the QRS complex

*Confusing as a P wave appearing before

the QRS complex in the face of a
tachycardia might honestly be read as a
sinus tachycardia..
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SCHEMATIC
OF TYPICAL
ATRIOVENT
RICULAR
NODAL
REENTRY.

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Left Panel: Anterograde conduction from the atrium (ATR)
to the ventricle (VTR) over both slow and fast pathways.
The ventricle is activated initially in sinus rhythm by the fast
pathway.
Centre Panel: The effect of a premature atrial complex
(PAC). Although the fast pathway conducts rapidly, it
repolarizes slowly. In this hypothetical scenario, the fast
pathway is refractory to the PAC, allowing the PAC to
proceed via the slow pathway, which has a shorter
refractory period.
Right Panel: Anterograde conduction of the PAC occurs via
the slow pathway, with subsequent recovery of the fast
pathway. These conditions allow retrograde conduction into
the atrium via the fast pathway, thereby creating the first
beat of typical slow-fast atrioventricular nodal reentrant
tachycardia.

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TATALAKSANA

Termination is often possible with valsalva

manouevres (blowing on wrist, squatting,
carotid sinus massage) or medication
(adenosine, verapamil, diltiazem), or
electrocardioversion.

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 Management
Patients may be instructed to undertake vagal manoeuvres upon the onset of
symptoms which can be effective in stopping the AVNRT. This may involve
carotid sinus massage or valsalva manoeuvres, which will both stimulate the
vagus nerve. Alternative strategies include:

Adenosine, beta-blockers or calcium channel blockers can suppress an

AVNRT event by blocking or slowing the AV node. Other second-line therapies
may include amiodarone or flecainide.

Cardioversion is rarely used on patients with AVNRT, usually when the

tachycardia is refractory to other medical therapies or the tachycardia is causing
haemodynamic instability (falling blood pressure, development of heart failure etc.)

Radiofrequency catheter ablation can be offered to patients with frequent attacks

for whom medical therapy isnt appropriate in the long term, and can be curative.

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DIAGNOSIS
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 Investigations
The ECG will typically show a tachycardia of 140-280 bpm with
normal and regular QRS complexes. There will be either
No visible P-waves (hidden within the QRS complex) or
P-waves immediately before the QRS or
P-waves immediately after the QRS complex
For recurrent episodes of palpitations, a Holter monitor and EPS may
be useful in identifying rhythms typical of AVNRT. An echocardiogram
may be useful in evaluating for structural heart disease and
electrophysiological studies may be necessary if considering ablative
therapy. Blood tests that may be appropriate in patients experiencing
palpitations include cardiac markers (to investigate for myocardial
infarction), urea and electrolytes (to identify imbalances in potassium,
magnesium or calcium) or thyroid function tests (hyperthyroidism may
trigger AVNRT or other arrhythmias).
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PROGNOSIS
The prognosis for patients with AVNRT is usually good in the absence of structural heart
disease. Most patients respond acutely to vagal maneuvers or adenosine and long term
to medications to prevent recurrence or to radiofrequency ablation, which is
approximately 95% curative and has a low risk of complications. It is the preferred
method of treatment for most patients.

One review of the literature concluded that cryoablation is safe and effective for AVNRT
and is an option in patients for whom the avoidance of AV block is a priority, such as
children and young adults. [3]

Complications of AVNRT include hemodynamic compromise, congestive heart

failure, syncope, tachycardia-induced angina, cardiomyopathy, myocardial ischemia,
and myocardial infarction.

23 https://emedicine.medscape.com
REFERENCE

www.khanacademy.org

emedicine.medscape.com

https://lifeinthefastlane.com/avnrt-ecg/

http://en.ecgpedia.org/wiki/AVNRT

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