Additional information about drug use is mandatory. Toxic levels of digoxin and cocain can lead to VT's. Anti-arrhythmics such as amiodarone can influence VT rate. Also additional information about family history of sudden cardiac death is helpfull, as it is a strong predictor of susceptibility to ventricular arrhythmias and sudden cardiac death. Physical Examination Although the diagnosis of VT is generally made by a 12 lead ECG, the following physical symptoms may be present: https://www.textbookofcardiology.org/wiki/Tachycardia 7/20 7/4/23, 12:17 AM Tachycardia - Textbook of Cardiology Decreased or variable amplitude of the carotid or peripheral pulses. This is related to the intermittent periods of atrial and ventricular synchronization, which transiently augment cardiac output. Cannon "A" waves on the jugular venous pulse in the neck. These represent intermittent retrograde propulsion of blood into the jugular veins during right atrial contraction against a closed AV valve. This is evidence of AV dissociation. Variable intensity of the first heart sound (although this is difficult with a rapid heart rate). Variable splitting of the first and second heart sounds, and intermittent presence of a third and/or fourth heart sound. Diagnostic Evaluation Exercise testing: Exercise testing is recommended in adult patients with ventricular tachycardias who have an intermediate or greater probability of having coronary heart disease by age, gender and symptoms. It is meant to provoke ischemic changes or ventricular arrhythmias. Ambulatory (Holter) ECG: An ambulatory ECG can be necessary if the diagnosis needs to be clarified, by detecting arrhythmias, QT-interval changes, T-wave alternans (TWA) or ST-segment changes. Echocardiography, Cardiac CT, MRI: Echocardiography is recommended in patients with ventricular tachycardias who are suspected of having a structural heart disease. If echocardiography does not provide accurate assessment of the left and right ventricular function and/or structural changes, cardiac CT or MRI can be done. Exercise testing with an image modality (echocardiography or nuclear perfusion): Some patients with ventricular arrhythmias have an intermediate probability of coronary heart disease, but their ECG is less reliable (because of digoxin use, LVH, greater than 1mm ST-segment depression at rest, WPW syndrome or LBBB). For detecting silent ischemia in these patients exercise testing with an image modality can be done. If patients are unable to perform exercise, a pharmacological stress test with an imaging modality can be done. Coronary angiography: Coronary angiography can diagnose or exclude the presence of significant obstructive coronary heart disease in patients with ventricular arrhythmias who have an intermediate or greater probability of having coronary heart disease. Electrophysiological testing: Electrophysiological testing can be performed to guide and assess the efficacy of VT ablation in patients with ventricular arrhythmias. It can also be done to clarify the mechanism of broad complex tachycardias in patients with coronary heart disease. Overview of ventricular tachycardias An overview of ventricular tachycardias, follow the Approach to the Wide Complex Tachycardia atrial frequency ventricular frequency origin (SVT/VT) example regularity p-wave effect of adenosine Wide complex (QRS>0.12) regular (mostly) ventricle (VT) AV- dissociation no rate reduction (sometimes accelerates) Ventricular Tachycardia 200px 60-100 bpm 110-250 bpm ventricle (VT) AV- dissociation Ventricular Fibrillation 200px irregular 60-100 bpm 400-600 bpm none ventricle (VT) AV- dissociation Ventricular Flutter 200px regular 60-100 bpm 150-300 bpm none Accelerated Idioventricular Rhythm regular (mostly) ventricle (VT) AV- dissociation no rate reduction (sometimes accelerates) 200px 60-100 bpm 50-110 bpm ventricle (VT) AV- dissociation no rate reduction (sometimes accelerates) Torsade de Pointes 200px regular 150-300 bpm Bundle-branch re- entrant tachycardia* ventricles (VT) AV- dissociation regular 60-100 bpm 150-300 bpm no rate reduction Bundle-branch re-entrant tachycardia is extremely rare Ventricular tachycardia Ventricular tachycardia (VT) is defined as a sequence of three or more ventricular beats. The rate is between 110-250 bpm. Ventricular tachycardias often origin around old scar tissue in the heart, e.g. after myocardial infarction. Also electrolyte disturbances and ischemia can cause ventricular tachycardias. The cardiac output is often strongly reduced during VT resulting in hypotension and loss of consciousness. VT is a medical emergency as it can deteriorate into ventricular fibrillation and thus mechanical cardiac arrest. Definitions Non-sustained VT: three or more ventricular beats with a maximal duration of 30 seconds. Sustained VT: a VT of more than 30 seconds duration (or less if treated by electrocardioversion within 30 seconds). Monomorphic VT: all ventricular beats have the same configuration. Polymorphic VT: the ventricular beats have a changing configuration. The heart rate is 100-333 bpm. Biphasic VT: a ventricular tachycardia with a QRS complex that alternates from beat to beat. Associated with digoxin intoxication and long QT syndrome. Localisation of the origin of a ventricular tachycardia https://www.textbookofcardiology.org/wiki/Tachycardia 8/20 7/4/23, 12:17 AM Tachycardia - Textbook of Cardiology Determination of the location (or exit site) where a ventricular tachycardia originated can be helpful in understanding the cause of the VT and is very helpful when planning an ablation procedure to treat a ventricular tachycardia. The location can be determined with the QRS morphology: RBBB/LBBB morphology: RBBB: origin in the left ventricle LBBB: origin in the right ventricle Inferior/superior axis (lead II, III and aVF): Inferior axis (positive in lead II, III and aVF): origin superior wall Superior axis (negative in lead II, III and aVF): origin inferior wall Basal/apical (lead V5-V6): Positive concordance in V5-6: basal origin Negative concordance in V5-6: apical origin Differential diagnosis (Non)sustained VT may be idiopathic, but occurs most frequently in patients with underlying structural heart disease of various types including: Coronary heart disease (CHD) with prior myocardial infarction. This is the most frequent cause in developed countries Hypertrophic cardiomyopathy Dilated cardiomyopathy Mitral valve prolapse Aortic stenosis Complex congenital heart disease Cardiac sarcoidosis Arrhythmogenic RV cardiomyopathy/dysplasia If no structural heart disease is present the differential diagnosis includes: Electrolyte disorders, especially hyper- / hypokalemia\ Drugs: e.g. digoxin Channelopathies (e.g. long QT syndrome, Brugada syndrome, CPVT) Idiopathic ventricular tachycardia (e.g. RVOT tachycardia, idiopathic left ventricular tachycardia) Purkinje VT s (e.g. Belhassen) Treatment Hemodynamical instability: Electrocardioversion Haemodynamical stability in a regular monomorphic broadcomplex tachycardia (systolic blood pressure >100 mmHg): Pharmacological treatment can be considered with Proca namide or Amiodaron Ventricular flutter Ventricular flutter is a ventricular tachycardia that occurs at a very rapid rate (often around 300 bpm), mostly caused by re-entry. The QRS complexes are regular and usually monomorphic and show a typical sinusoidal pattern. During ventricular flutter the ventricles depolarize in a circular pattern, which prevents good function. Most often this results in a minimal cardiac output and subsequent ischemia. Often deteriorates into ventricular fibrillation. Treatment Treatment Electrocardioversion is the only treatment for ventricular flutter. Ventricular fibrillation https://www.textbookofcardiology.org/wiki/Tachycardia 9/20 7/4/23, 12:17 AM Tachycardia - Textbook of Cardiology Ventricular fibrillation (VF) is identified by the complete absence of properly formed QRS complexes and no obvious P waves. Instead of uniform activation of the ventricular myocardium, there are unco rdinated series of very rapid, ineffective contractions of the ventricle caused by many chaotic electrical impulses. In recent onset VF the QRS complexes are of high amplitude at rates greater than 320 bpm, which manifest random changes in morphology, width and height. It appears as a completely chaotic rhythm. If VF continues, the fibrillatory waves become fine and can resemble asystole in these cases. Treatment VF is lethal if the patient is not treated immediately. It gives rise to a mechanical standstill of the heart, because the heart is not able to pump normally anymore. Electrocardioversion is the only treatment for ventricular fibrillation. Accelerated idio-ventricular rhythm Accelerated idioventricular rhythm (AIVR) is a relatively benign form of ventricular tachycardia. It is (mostly) a regular repetitive ventricular rhythm with a rate around 60-120 bpm, but mostly 80-100. It is the result of an enhanced ectopic ventricular rhythm, which is faster than normal intrinsic ventricular escape rhythm (<40 bpm), but slower than ventricular tachycardia (over 100-120 bpm). It often occurs during reperfusion after a myocardial infarction. AIVR is not predictive marker for early VF; however, recent debate has started whether among patients with successfull coronary intervention, AIVR is a sign of ventricular dysfunction and therefore a slightly worse prognosis. AIVR can also occur in infants. By this definition, this is a ventricular rhythm of no more than 20% faster than the sinus rate and occuring in the absence of other heart disease. This arrhythmia typically resolves spontaneously during the first months of life (in contrast to an infant with incessant VT which can be due to discrete myocardial tumors or congenital cardiomyopathy). Treatment AIVR is generally a transient, self-limiting rhythm and resolves as sinus rate surpasses the rate of AIVR. It rarely causes hemodynamic instability and rarely requires treatment. Torsades de Pointes Torsade de pointes (TdP) is a ventricular tachycardia associated with a prolonged QTc interval on the resting ECG. The ECG is characterized by twisting of the peaks of the QRS complexes around the isoelectric baseline during the arrhythmia (changing axis). Torsade de pointes is initiated by a short-long-short interval. A ventricle extrasystole (first beat: short) is followed by a compensatory pause. The following beat (second beat: long) has a longer QT interval. If the next beat follows shortly thereafter, there is a good chance that this third beat falls within the QT interval, resulting in the R on T phenomenon and subsequent Torsades de pointes. Causes of Torsade de Pointes Torsade de Pointes, preceded by bigemini. Aquired long QT syndrome (complete list of drugs causing long QT syndrome: http://www.torsades.org http://www.torsades.org]) https://www.textbookofcardiology.org/wiki/Tachycardia 10/20 7/4/23, 12:17 AM Tachycardia - Textbook of Cardiology Congenital long QT syndrome Concomittant risk factors for medication induced torsade de pointes: 1. Female sex 2. Hypokalemia 3. Bradycardia 4. Recent conversion of atrial fibrillation, especially if QT prolonging drugs were used (sotalol, amiodarone) 5. Cardiac decompensation 6. Digoxin treatment 7. High or overdosing or rapid infusion of a QT prolonging drug 8. Pre-existing QT prolongation 9. Congenital QT syndrome Notorious QT prolonging drugs: 1. Amiodarone 2. Chloroquine 3. Chlorpromazine 4. Citalopram 5. Claritromycin 6. Disopyramide 7. Dofetilide 8. Erythromycin 9. Flecainide 10. Halofantrine 11. Haloperidol 12. Quinidine 13. Sotalol Treatment Electrocardioversion is the first treatment for TdP. Additional treatments are: Withdrawal of any offending drugs and correction of electrolyte abnormalities (potassium repletion up to 4.5 to 5 mmol/liter). Acute and long-term cardiac pacing in patients with TdP presenting with heart block, symptomatic bradycardia or recurrent pause-dependent TdP Intravenous magnesium sulfate for patients with QT prolongation and few episodes of TdP. Beta blockers combined with cardiac pacing as acute therapy for patients with TdP and sinus bradycardia. Isoproterenol as temporary treatment in patients with recurrent pause-dependent TdP who do not have congenital long QT syndrome. Differentiation between SVT and VT To differentiate between supraventricular tachycardias and ventricular tachycardias a 12 lead ECG is the cornerstone of the diagnostic process. At first, the physician has to make a differentiation between a narrow or wide complex tachycardia. Definitions Narrow complex tachycardia: QRS duration < 120 ms. A narrow complex tachycardia is most likely to be a SVT. However, also a septal VT or His-tachycardia can appear as a narrow complex tachycardia. Wide complex tachycardia: QRS duration > 120 ms. A wide complex tachycardia can be due to a SVT with aberration, pre-exited tachycardia (eg antidrome re-entry tachycardia) or VT. Differentiation These are the flow charts of a small and wide complex tachycardia to differentiate between the different rhythms: https://www.textbookofcardiology.org/wiki/Tachycardia 11/20 7/4/23, 12:17 AM Tachycardia - Textbook of Cardiology Treatment Haemodynamical instability (systolic blood pressure less than 100 mmHg): electrical cardioversion Haemodynamical stability in a regular small complex tachycardia: Carotid massage (after palpation and ausculatation of carotid arteries for exclusion of carotid occlusion/stenosis) Vasalva manoeuvre Adenosine bolus (if patient is not asthmatic or having COPD) Verapamil (if patient is not having systolic heart failure) Beta-blocker (if patient is not having systolic heart failure) References 3. Ghuran A, van Der Wieken LR, and Nolan J. Cardiovascular complications of recreational drugs. BMJ. 2001 Sep 1;323(7311):464-6. DOI:10.1136/bmj.323.7311.464 | 4. Coss SF and Steinberg JS. Supraventricular tachyarrhythmias involving the sinus node: clinical and electrophysiologic characteristics. Prog Cardiovasc Dis. 1998 Jul-Aug;41(1):51-63. DOI:10.1016/s0033-0620(98)80022-4 | 6. ECGpedia (http://en.ecgpedia.org) 7. Saoudi N, Cos o F, Waldo A, Chen SA, Iesaka Y, Lesh M, Saksena S, Salerno J, Schoels W, and Working Group of Arrhythmias of the European of Cardiology and the North American Society of Pacing and Electrophysiology. A classification of atrial flutter and regular atrial tachycardia according to electrophysiological mechanisms and anatomical bases; a Statement from a Joint Expert Group from The Working Group of Arrhythmias of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Eur Heart J. 2001 Jul;22(14):1162-82. DOI:10.1053/euhj.2001.2658 | 9. Markowitz SM, Stein KM, Mittal S, Slotwiner DJ, and Lerman BB. Differential effects of adenosine on focal and macroreentrant atrial tachycardia. J Cardiovasc Electrophysiol. 1999 Apr;10(4):489-502. DOI:10.1111/j.1540-8167.1999.tb00705.x | 10. Chen SA, Chiang CE, Yang CJ, Cheng CC, Wu TJ, Wang SP, Chiang BN, and Chang MS. Sustained atrial tachycardia in adult patients. Electrophysiological characteristics, pharmacological response, possible mechanisms, and effects of radiofrequency ablation. Circulation. 1994 Sep;90(3):1262-78. DOI:10.1161/01.cir.90.3.1262 | 11. Chen SA, Tai CT, Chiang CE, Ding YA, and Chang MS. Focal atrial tachycardia: reanalysis of the clinical and electrophysiologic characteristics and prediction of successful radiofrequency ablation. J Cardiovasc Electrophysiol. 1998 Apr;9(4):355-65. DOI:10.1111/j.1540- 8167.1998.tb00924.x | 12. Anguera I, Brugada J, Roba M, Mont L, Aguinaga L, Geelen P, and Brugada P. Outcomes after radiofrequency catheter ablation of atrial tachycardia. Am J Cardiol. 2001 Apr 1;87(7):886-90. DOI:10.1016/s0002-9149(00)01531-9 | 13. Yang Y, Cheng J, Bochoeyer A, Hamdan MH, Kowal RC, Page R, Lee RJ, Steiner PR, Saxon LA, Lesh MD, Modin GW, and Scheinman MM. Atypical right atrial flutter patterns. Circulation. 2001 Jun 26;103(25):3092-8. DOI:10.1161/01.cir.103.25.3092 | 14. Bochoeyer A, Yang Y, Cheng J, Lee RJ, Keung EC, Marrouche NF, Natale A, and Scheinman MM. Surface electrocardiographic characteristics of right and left atrial flutter. Circulation. 2003 Jul 8;108(1):60-6. DOI:10.1161/01.CIR.0000079140.35025.1E | 15. Volgman AS, Carberry PA, Stambler B, Lewis WR, Dunn GH, Perry KT, Vanderlugt JT, and Kowey PR. Conversion efficacy and safety of intravenous ibutilide compared with intravenous procainamide in patients with atrial flutter or fibrillation. J Am Coll Cardiol. 1998 May;31(6):1414- 9. DOI:10.1016/s0735-1097(98)00078-3 | https://www.textbookofcardiology.org/wiki/Tachycardia 12/20 7/4/23, 12:17 AM Tachycardia - Textbook of Cardiology 16. Singh S, Zoble RG, Yellen L, Brodsky MA, Feld GK, Berk M, and Billing CB Jr. Efficacy and safety of oral dofetilide in converting to and maintaining sinus rhythm in patients with chronic atrial fibrillation or atrial flutter: the symptomatic atrial fibrillation investigative research on dofetilide (SAFIRE-D) study. Circulation. 2000 Nov 7;102(19):2385-90. DOI:10.1161/01.cir.102.19.2385 | 17. Stambler BS, Wood MA, and Ellenbogen KA. Antiarrhythmic actions of intravenous ibutilide compared with procainamide during human atrial flutter and fibrillation: electrophysiological determinants of enhanced conversion efficacy. Circulation. 1997 Dec 16;96(12):4298-306. DOI:10.1161/01.cir.96.12.4298 | 18. Kottkamp H, H gl B, Krauss B, Wetzel U, Fleck A, Schuler G, and Hindricks G. Electromagnetic versus fluoroscopic mapping of the inferior isthmus for ablation of typical atrial flutter: A prospective randomized study. Circulation. 2000 Oct 24;102(17):2082-6. DOI:10.1161/01.cir.102.17.2082 | 19. Natale A, Newby KH, Pisan E, Leonelli F, Fanelli R, Potenza D, Beheiry S, and Tomassoni G. Prospective randomized comparison of antiarrhythmic therapy versus first-line radiofrequency ablation in patients with atrial flutter. J Am Coll Cardiol. 2000 Jun;35(7):1898-904. DOI:10.1016/s0735-1097(00)00635-5 | 20. Chen SA, Chiang CE, Wu TJ, Tai CT, Lee SH, Cheng CC, Chiou CW, Ueng KC, Wen ZC, and Chang MS. Radiofrequency catheter ablation of common atrial flutter: comparison of electrophysiologically guided focal ablation technique and linear ablation technique. J Am Coll Cardiol. 1996 Mar 15;27(4):860-8. DOI:10.1016/0735-1097(95)00565-x | 21. Dunn MI. Thrombolism with atrial flutter. Am J Cardiol. 1998 Sep 1;82(5):638. DOI:10.1016/s0002-9149(98)00420-2 | 22. Lip GY and Kamath S. Thromboprophylaxis for atrial flutter. Eur Heart J. 2001 Jun;22(12):984-7. DOI:10.1053/euhj.2000.2490 | 23. Schotten U, Verheule S, Kirchhof P, and Goette A. Pathophysiological mechanisms of atrial fibrillation: a translational appraisal. Physiol Rev. 2011 Jan;91(1):265-325. DOI:10.1152/physrev.00031.2009 | 24. Patterson E, Po SS, Scherlag BJ, and Lazzara R. Triggered firing in pulmonary veins initiated by in vitro autonomic nerve stimulation. Heart Rhythm. 2005 Jun;2(6):624-31. DOI:10.1016/j.hrthm.2005.02.012 | 25. Wijffels MC, Kirchhof CJ, Dorland R, and Allessie MA. Atrial fibrillation begets atrial fibrillation. A study in awake chronically instrumented goats. Circulation. 1995 Oct 1;92(7):1954-68. DOI:10.1161/01.cir.92.7.1954 | 26. Watson T, Shantsila E, and Lip GY. Mechanisms of thrombogenesis in atrial fibrillation: Virchow's triad revisited. Lancet. 2009 Jan 10;373(9658):155-66. DOI:10.1016/S0140-6736(09)60040-4 | 27. Packer DL, Bardy GH, Worley SJ, Smith MS, Cobb FR, Coleman RE, Gallagher JJ, and German LD. Tachycardia-induced cardiomyopathy: a reversible form of left ventricular dysfunction. Am J Cardiol. 1986 Mar 1;57(8):563-70. DOI:10.1016/0002-9149(86)90836-2 | 28. Nieuwlaat R, Capucci A, Camm AJ, Olsson SB, Andresen D, Davies DW, Cobbe S, Breithardt G, Le Heuzey JY, Prins MH, L vy S, Crijns HJ, and European Heart Survey Investigators. Atrial fibrillation management: a prospective survey in ESC member countries: the Euro Heart Survey on Atrial Fibrillation. Eur Heart J. 2005 Nov;26(22):2422-34. DOI:10.1093/eurheartj/ehi505 | 29. Jahangir A, Lee V, Friedman PA, Trusty JM, Hodge DO, Kopecky SL, Packer DL, Hammill SC, Shen WK, and Gersh BJ. Long-term progression and outcomes with aging in patients with lone atrial fibrillation: a 30-year follow-up study. Circulation. 2007 Jun 19;115(24):3050-6. DOI:10.1161/CIRCULATIONAHA.106.644484 | 30. European Heart Rhythm Association, European Association for Cardio-Thoracic Surgery, Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, Van Gelder IC, Al-Attar N, Hindricks G, Prendergast B, Heidbuchel H, Alfieri O, Angelini A, Atar D, Colonna P, De Caterina R, De Sutter J, Goette A, Gorenek B, Heldal M, Hohloser SH, Kolh P, Le Heuzey JY, Ponikowski P, and Rutten FH. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010 Oct;31(19):2369-429. DOI:10.1093/eurheartj/ehq278 | 31. Friberg L, Hammar N, and Rosenqvist M. Stroke in paroxysmal atrial fibrillation: report from the Stockholm Cohort of Atrial Fibrillation. Eur Heart J. 2010 Apr;31(8):967-75. DOI:10.1093/eurheartj/ehn599 | 32. European Heart Rhythm Association, European Association for Cardio-Thoracic Surgery, Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, Van Gelder IC, Al-Attar N, Hindricks G, Prendergast B, Heidbuchel H, Alfieri O, Angelini A, Atar D, Colonna P, De Caterina R, De Sutter J, Goette A, Gorenek B, Heldal M, Hohloser SH, Kolh P, Le Heuzey JY, Ponikowski P, and Rutten FH. Guidelines for the management of atrial fibrillation: the Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). Eur Heart J. 2010 Oct;31(19):2369-429. DOI:10.1093/eurheartj/ehq278 | 33. Mart nez-Marcos FJ, Garc a-Garmendia JL, Ortega-Carpio A, Fern ndez-G mez JM, Santos JM, and Camacho C. Comparison of intravenous flecainide, propafenone, and amiodarone for conversion of acute atrial fibrillation to sinus rhythm. Am J Cardiol. 2000 Nov 1;86(9):950-3. DOI:10.1016/s0002-9149(00)01128-0 | 34. Chevalier P, Durand-Dubief A, Burri H, Cucherat M, Kirkorian G, and Touboul P. Amiodarone versus placebo and class Ic drugs for cardioversion of recent-onset atrial fibrillation: a meta-analysis. J Am Coll Cardiol. 2003 Jan 15;41(2):255-62. DOI:10.1016/s0735-1097(02)02705-5 | 35. Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, Hindricks G, Kirchhof P, and ESC Committee for Practice Guidelines (CPG). 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012 Nov;33(21):2719-47. DOI:10.1093/eurheartj/ehs253 | 36. Van Gelder IC, Hagens VE, Bosker HA, Kingma JH, Kamp O, Kingma T, Said SA, Darmanata JI, Timmermans AJ, Tijssen JG, Crijns HJ, and Rate Control versus Electrical Cardioversion for Persistent Atrial Fibrillation Study Group. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. N Engl J Med. 2002 Dec 5;347(23):1834-40. DOI:10.1056/NEJMoa021375 | 37. Van Gelder IC, Groenveld HF, Crijns HJ, Tuininga YS, Tijssen JG, Alings AM, Hillege HL, Bergsma-Kadijk JA, Cornel JH, Kamp O, Tukkie R, Bosker HA, Van Veldhuisen DJ, Van den Berg MP, and RACE II Investigators. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010 Apr 15;362(15):1363-73. DOI:10.1056/NEJMoa1001337 | 38. Groenveld HF, Crijns HJ, Van den Berg MP, Van Sonderen E, Alings AM, Tijssen JG, Hillege HL, Tuininga YS, Van Veldhuisen DJ, Ranchor AV, Van Gelder IC, and RACE II Investigators. The effect of rate control on quality of life in patients with permanent atrial fibrillation: data from the RACE II (Rate Control Efficacy in Permanent Atrial Fibrillation II) study. J Am Coll Cardiol. 2011 Oct 18;58(17):1795-803. DOI:10.1016/j.jacc.2011.06.055 | 39. Whitbeck MG, Charnigo RJ, Khairy P, Ziada K, Bailey AL, Zegarra MM, Shah J, Morales G, Macaulay T, Sorrell VL, Campbell CL, Gurley J, Anaya P, Nasr H, Bai R, Di Biase L, Booth DC, Jondeau G, Natale A, Roy D, Smyth S, Moliterno DJ, and Elayi CS. Increased mortality among patients taking digoxin analysis from the AFFIRM study. Eur Heart J. 2013 May;34(20):1481-8. DOI:10.1093/eurheartj/ehs348 | 40. Lafuente-Lafuente C, Longas-Tejero MA, Bergmann JF, and Belmin J. Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation. Cochrane Database Syst Rev. 2012 May 16(5):CD005049. DOI:10.1002/14651858.CD005049.pub3 | 41. Echt DS, Liebson PR, Mitchell LB, Peters RW, Obias-Manno D, Barker AH, Arensberg D, Baker A, Friedman L, and Greene HL. Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial. N Engl J Med. 1991 Mar https://www.textbookofcardiology.org/wiki/Tachycardia 13/20 7/4/23, 12:17 AM Tachycardia - Textbook of Cardiology 21;324(12):781-8. DOI:10.1056/NEJM199103213241201 | 42. Roy D, Talajic M, Dorian P, Connolly S, Eisenberg MJ, Green M, Kus T, Lambert J, Dubuc M, Gagn P, Nattel S, and Thibault B. Amiodarone to prevent recurrence of atrial fibrillation. Canadian Trial of Atrial Fibrillation Investigators. N Engl J Med. 2000 Mar 30;342(13):913-20. DOI:10.1056/NEJM200003303421302 | 43. Ahmed S, Rienstra M, Crijns HJ, Links TP, Wiesfeld AC, Hillege HL, Bosker HA, Lok DJ, Van Veldhuisen DJ, Van Gelder IC, and CONVERT Investigators. Continuous vs episodic prophylactic treatment with amiodarone for the prevention of atrial fibrillation: a randomized trial. JAMA. 2008 Oct 15;300(15):1784-92. DOI:10.1001/jama.300.15.1784 | 44. Calkins H, Kuck KH, Cappato R, Brugada J, Camm AJ, Chen SA, Crijns HJ, Damiano RJ Jr, Davies DW, DiMarco J, Edgerton J, Ellenbogen K, Ezekowitz MD, Haines DE, Haissaguerre M, Hindricks G, Iesaka Y, Jackman W, Jalife J, Jais P, Kalman J, Keane D, Kim YH, Kirchhof P, Klein G, Kottkamp H, Kumagai K, Lindsay BD, Mansour M, Marchlinski FE, McCarthy PM, Mont JL, Morady F, Nademanee K, Nakagawa H, Natale A, Nattel S, Packer DL, Pappone C, Prystowsky E, Raviele A, Reddy V, Ruskin JN, Shemin RJ, Tsao HM, Wilber D, and Heart Rhythm Society Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. 2012 HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation: recommendations for patient selection, procedural techniques, patient management and follow-up, definitions, endpoints, and research trial design: a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation. Developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology (ESC) and the European Cardiac Arrhythmia Society (ECAS); and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). Endorsed by the governing bodies of the American College of Cardiology Foundation, the American Heart Association, the European Cardiac Arrhythmia Society, the European Heart Rhythm Association, the Society of Thoracic Surgeons, the Asia Pacific Heart Rhythm Society, and the Heart Rhythm Society. Heart Rhythm. 2012 Apr;9(4):632-696.e21. DOI:10.1016/j.hrthm.2011.12.016 | 45. Ha ssaguerre M, Ja s P, Shah DC, Takahashi A, Hocini M, Quiniou G, Garrigue S, Le Mouroux A, Le M tayer P, and Cl menty J. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998 Sep 3;339(10):659-66. DOI:10.1056/NEJM199809033391003 | 46. Calkins H, Reynolds MR, Spector P, Sondhi M, Xu Y, Martin A, Williams CJ, and Sledge I. Treatment of atrial fibrillation with antiarrhythmic drugs or radiofrequency ablation: two systematic literature reviews and meta-analyses. Circ Arrhythm Electrophysiol. 2009 Aug;2(4):349-61. DOI:10.1161/CIRCEP.108.824789 | 47. Calkins H, Reynolds MR, Spector P, Sondhi M, Xu Y, Martin A, Williams CJ, and Sledge I. Treatment of atrial fibrillation with antiarrhythmic drugs or radiofrequency ablation: two systematic literature reviews and meta-analyses. Circ Arrhythm Electrophysiol. 2009 Aug;2(4):349-61. DOI:10.1161/CIRCEP.108.824789 | 48. Cosedis Nielsen J, Johannessen A, Raatikainen P, Hindricks G, Walfridsson H, Kongstad O, Pehrson S, Englund A, Hartikainen J, Mortensen LS, and Hansen PS. Radiofrequency ablation as initial therapy in paroxysmal atrial fibrillation. N Engl J Med. 2012 Oct 25;367(17):1587-95. DOI:10.1056/NEJMoa1113566 | 49. Khan MN, Ja s P, Cummings J, Di Biase L, Sanders P, Martin DO, Kautzner J, Hao S, Themistoclakis S, Fanelli R, Potenza D, Massaro R, Wazni O, Schweikert R, Saliba W, Wang P, Al-Ahmad A, Beheiry S, Santarelli P, Starling RC, Dello Russo A, Pelargonio G, Brachmann J, Schibgilla V, Bonso A, Casella M, Raviele A, Ha ssaguerre M, Natale A, and PABA-CHF Investigators. Pulmonary-vein isolation for atrial fibrillation in patients with heart failure. N Engl J Med. 2008 Oct 23;359(17):1778-85. DOI:10.1056/NEJMoa0708234 | 50. Hsu LF, Ja s P, Sanders P, Garrigue S, Hocini M, Sacher F, Takahashi Y, Rotter M, Pasqui JL, Scav e C, Bordachar P, Cl menty J, and Ha ssaguerre M. Catheter ablation for atrial fibrillation in congestive heart failure. N Engl J Med. 2004 Dec 2;351(23):2373-83. DOI:10.1056/NEJMoa041018 | 51. Krul SP, Driessen AH, Zwinderman AH, van Boven WJ, Wilde AA, de Bakker JM, and de Groot JR. Navigating the mini-maze: systematic review of the first results and progress of minimally-invasive surgery in the treatment of atrial fibrillation. Int J Cardiol. 2013 Jun 5;166(1):132-40. DOI:10.1016/j.ijcard.2011.10.011 | 52. Pison L, La Meir M, van Opstal J, Blaauw Y, Maessen J, and Crijns HJ. Hybrid thoracoscopic surgical and transvenous catheter ablation of atrial fibrillation. J Am Coll Cardiol. 2012 Jul 3;60(1):54-61. DOI:10.1016/j.jacc.2011.12.055 | 53. Carlsson J, Miketic S, Windeler J, Cuneo A, Haun S, Micus S, Walter S, Tebbe U, and STAF Investigators. Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation (STAF) study. J Am Coll Cardiol. 2003 May 21;41(10):1690-6. DOI:10.1016/s0735-1097(03)00332-2 | 54. Hohnloser SH, Kuck KH, and Lilienthal J. Rhythm or rate control in atrial fibrillation Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomised trial. Lancet. 2000 Nov 25;356(9244):1789-94. DOI:10.1016/s0140-6736(00)03230-x | 55. Opolski G, Torbicki A, Kosior DA, Szulc M, Wozakowska-Kaplon B, Kolodziej P, Achremczyk P, and Investigators of the Polish How to Treat Chronic Atrial Fibrillation Study. Rate control vs rhythm control in patients with nonvalvular persistent atrial fibrillation: the results of the Polish How to Treat Chronic Atrial Fibrillation (HOT CAFE) Study. Chest. 2004 Aug;126(2):476-86. DOI:10.1378/chest.126.2.476 | 56. Wyse DG, Waldo AL, DiMarco JP, Domanski MJ, Rosenberg Y, Schron EB, Kellen JC, Greene HL, Mickel MC, Dalquist JE, Corley SD, and Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002 Dec 5;347(23):1825-33. DOI:10.1056/NEJMoa021328 | 57. Ogawa S, Yamashita T, Yamazaki T, Aizawa Y, Atarashi H, Inoue H, Ohe T, Ohtsu H, Okumura K, Katoh T, Kamakura S, Kumagai K, Kurachi Y, Kodama I, Koretsune Y, Saikawa T, Sakurai M, Sugi K, Tabuchi T, Nakaya H, Nakayama T, Hirai M, Fukatani M, Mitamura H, and J-RHYTHM Investigators. Optimal treatment strategy for patients with paroxysmal atrial fibrillation: J-RHYTHM Study. Circ J. 2009 Feb;73(2):242-8. DOI:10.1253/circj.cj-08-0608 | 58. Ionescu-Ittu R, Abrahamowicz M, Jackevicius CA, Essebag V, Eisenberg MJ, Wynant W, Richard H, and Pilote L. Comparative effectiveness of rhythm control vs rate control drug treatment effect on mortality in patients with atrial fibrillation. Arch Intern Med. 2012 Jul 9;172(13):997-1004. DOI:10.1001/archinternmed.2012.2266 | 59. Camm AJ, Breithardt G, Crijns H, Dorian P, Kowey P, Le Heuzey JY, Merioua I, Pedrazzini L, Prystowsky EN, Schwartz PJ, Torp-Pedersen C, and Weintraub W. Real-life observations of clinical outcomes with rhythm- and rate-control therapies for atrial fibrillation RECORDAF (Registry on Cardiac Rhythm Disorders Assessing the Control of Atrial Fibrillation). J Am Coll Cardiol. 2011 Jul 26;58(5):493-501. DOI:10.1016/j.jacc.2011.03.034 | 60. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, Pogue J, Reilly PA, Themeles E, Varrone J, Wang S, Alings M, Xavier D, Zhu J, Diaz R, Lewis BS, Darius H, Diener HC, Joyner CD, Wallentin L, and RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009 Sep 17;361(12):1139-51. DOI:10.1056/NEJMoa0905561 | 61. Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, Breithardt G, Halperin JL, Hankey GJ, Piccini JP, Becker RC, Nessel CC, Paolini JF, Berkowitz SD, Fox KA, Califf RM, and ROCKET AF Investigators. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011 Sep 8;365(10):883-91. DOI:10.1056/NEJMoa1009638 | https://www.textbookofcardiology.org/wiki/Tachycardia 14/20 7/4/23, 12:17 AM Tachycardia - Textbook of Cardiology 62. Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, Al-Khalidi HR, Ansell J, Atar D, Avezum A, Bahit MC, Diaz R, Easton JD, Ezekowitz JA, Flaker G, Garcia D, Geraldes M, Gersh BJ, Golitsyn S, Goto S, Hermosillo AG, Hohnloser SH, Horowitz J, Mohan P, Jansky P, Lewis BS, Lopez-Sendon JL, Pais P, Parkhomenko A, Verheugt FW, Zhu J, Wallentin L, and ARISTOTLE Committees and Investigators. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011 Sep 15;365(11):981-92. DOI:10.1056/NEJMoa1107039 | 63. Wu J and Zipes DP. Mechanisms underlying atrioventricular nodal conduction and the reentrant circuit of atrioventricular nodal reentrant tachycardia using optical mapping. J Cardiovasc Electrophysiol. 2002 Aug;13(8):831-4. DOI:10.1046/j.1540-8167.2002.00831.x | 64. Akhtar M, Jazayeri MR, Sra J, Blanck Z, Deshpande S, and Dhala A. Atrioventricular nodal reentry. Clinical, electrophysiological, and therapeutic considerations. Circulation. 1993 Jul;88(1):282-95. DOI:10.1161/01.cir.88.1.282 | 65. Clague JR, Dagres N, Kottkamp H, Breithardt G, and Borggrefe M. Targeting the slow pathway for atrioventricular nodal reentrant tachycardia: initial results and long-term follow-up in 379 consecutive patients. Eur Heart J. 2001 Jan;22(1):82-8. DOI:10.1053/euhj.2000.2124 | 66. Alboni P, Tomasi C, Menozzi C, Bottoni N, Paparella N, Fuc G, Brignole M, and Cappato R. Efficacy and safety of out-of-hospital self- administered single-dose oral drug treatment in the management of infrequent, well-tolerated paroxysmal supraventricular tachycardia. J Am Coll Cardiol. 2001 Feb;37(2):548-53. DOI:10.1016/s0735-1097(00)01128-1 | 67. Becker AE, Anderson RH, Durrer D, and Wellens HJ. The anatomical substrates of wolff-parkinson-white syndrome. A clinicopathologic correlation in seven patients. Circulation. 1978 May;57(5):870-9. DOI:10.1161/01.cir.57.5.870 | 68. Cos o FG, Anderson RH, Kuck KH, Becker A, Borggrefe M, Campbell RW, Gaita F, Guiraudon GM, Ha ssaguerre M, Rufilanchas JJ, Thiene G, Wellens HJ, Langberg J, Benditt DG, Bharati S, Klein G, Marchlinski F, and Saksena S. Living anatomy of the atrioventricular junctions. A guide to electrophysiologic mapping. A Consensus Statement from the Cardiac Nomenclature Study Group, Working Group of Arrhythmias, European Society of Cardiology, and the Task Force on Cardiac Nomenclature from NASPE. Circulation. 1999 Aug 3;100(5):e31-7. DOI:10.1161/01.cir.100.5.e31 | 69. Wolff L, Parkinson J, and White PD. Bundle-branch block with short P-R interval in healthy young people prone to paroxysmal tachycardia. 1930. Ann Noninvasive Electrocardiol. 2006 Oct;11(4):340-53. DOI:10.1111/j.1542-474X.2006.00127.x | 70. Tebbenjohanns J, Pfeiffer D, Schumacher B, Jung W, Manz M, and L deritz B. Intravenous adenosine during atrioventricular reentrant tachycardia: induction of atrial fibrillation with rapid conduction over an accessory pathway. Pacing Clin Electrophysiol. 1995 Apr;18(4 Pt 1):743- 6. DOI:10.1111/j.1540-8159.1995.tb04673.x | 71. Pediatric and Congenital Electrophysiology Society (PACES), Heart Rhythm Society (HRS), American College of Cardiology Foundation (ACCF), American Heart Association (AHA), American Academy of Pediatrics (AAP), Canadian Heart Rhythm Society (CHRS), Cohen MI, Triedman JK, Cannon BC, Davis AM, Drago F, Janousek J, Klein GJ, Law IH, Morady FJ, Paul T, Perry JC, Sanatani S, and Tanel RE. PACES/HRS expert consensus statement on the management of the asymptomatic young patient with a Wolff-Parkinson-White (WPW, ventricular preexcitation) electrocardiographic pattern: developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology Foundation (ACCF), the American Heart Association (AHA), the American Academy of Pediatrics (AAP), and the Canadian Heart Rhythm Society (CHRS). Heart Rhythm. 2012 Jun;9(6):1006-24. DOI:10.1016/j.hrthm.2012.03.050 | 72. Roden DM. Drug-induced prolongation of the QT interval. N Engl J Med. 2004 Mar 4;350(10):1013-22. DOI:10.1056/NEJMra032426 | 73. Cox JL, Schuessler RB, D'Agostino HJ Jr, Stone CM, Chang BC, Cain ME, Corr PB, and Boineau JP. The surgical treatment of atrial fibrillation. III. Development of a definitive surgical procedure. J Thorac Cardiovasc Surg. 1991 Apr;101(4):569-83. 74. Cox JL. The surgical treatment of atrial fibrillation. IV. Surgical technique. J Thorac Cardiovasc Surg. 1991 Apr;101(4):584-92. 75. Wolf RK, Schneeberger EW, Osterday R, Miller D, Merrill W, Flege JB Jr, and Gillinov AM. Video-assisted bilateral pulmonary vein isolation and left atrial appendage exclusion for atrial fibrillation. J Thorac Cardiovasc Surg. 2005 Sep;130(3):797-802. DOI:10.1016/j.jtcvs.2005.03.041 | 76. Boersma LV, Castella M, van Boven W, Berruezo A, Yilmaz A, Nadal M, Sandoval E, Calvo N, Brugada J, Kelder J, Wijffels M, and Mont L. Atrial fibrillation catheter ablation versus surgical ablation treatment (FAST): a 2-center randomized clinical trial. Circulation. 2012 Jan 3;125(1):23-30. DOI:10.1161/CIRCULATIONAHA.111.074047 | 77. de Groot JR, Driessen AH, Van Boven WJ, Krul SP, Linnenbank AC, Jackman WM, and De Bakker JM. Epicardial confirmation of conduction block during thoracoscopic surgery for atrial fibrillation a hybrid surgical-electrophysiological approach. Minim Invasive Ther Allied Technol. 2012 Jul;21(4):293-301. DOI:10.3109/13645706.2011.615329 | 78. La Meir M, Gelsomino S, Luc F, Pison L, Colella A, Lorusso R, Crudeli E, Gensini GF, Crijns HG, and Maessen J. Minimal invasive surgery for atrial fibrillation: an updated review. Europace. 2013 Feb;15(2):170-82. DOI:10.1093/europace/eus216 | 79. Lip GY, Frison L, Halperin JL, and Lane DA. Identifying patients at high risk for stroke despite anticoagulation: a comparison of contemporary