Skip to main content
SpringerLink
Log in
Book cover

Die Notfalltherapie bei akuten Herzrhythmusstörungen pp 15–27Cite as

Diagnostik und Therapie von Tachykardien mit schmalem QRS-Komplex

Diagnosis and therapy in narrow QRS tachycardia

  • Chapter

Summary

Emergency medicine and critical care are fields that often require rapid diagnosis and intervention for specific situations. Narrow QRS tachycardia is a cardiac rhythm with a rate faster than 100/min and a QRS duration <0.12 s. Causes of narrow QRS tachycardia (N-QRS-T) are sinus tachycardia (ST), atrial tachycardia (AT), AV nodal reentry tachycardia (AVNRT), circus movement tachycardia (CMT), atrial flutter (AFlut) and atrial fibrillation (AFib). A systematic ECG approach with evaluation of spontaneous AV block, QRS alternans, P wave location and P wave polarity permits correct identification of the underlying arrhythmia mechanism and the origin of the arrhythmia. In hemodynamically unstable N-QRS-T, electrical DC cardioversion should be performed immediately. If the hemodynamic situation is stable, vagal maneuvers (Valsalva, carotis sinus massage) are indicated; if unsuccessful, drugs are therapeutic alternatives. In ST, beta-blocking agents (metoprolol 15 mg i.v.) are successful; in AT and AVNRT adenosine (6–18 mg bolus i.v.) and ajmaline (50–100 mg i.v.) are preferred. In patients (pts) with CMT, ajmaline (50–100 mg i.v.) is an ideal drug with high success rates. When vagal maneuvers or pharmacologic interventions fail to suppress the N-QRS-T, DC cardioversion is necessary. For pts with AFib principles of therapy are restoration of sinus rhythm (RSR) or ventricular rate control. Direct current cardioversion can restore sinus rhythm in up to 90% of pts with AFib. No single agent has emerged as the drug of choice for converting AFib; however, RSR is possible with propafenone (600 mg oral), flecainide (300 mg oral) or sotalol (80–160 mg oral). Ventricular rate control is an important component in pts with AFib. Verapamil (5–10 mg i.v.) and digoxin (0.4 mg i.v.) are effective drugs in reducing resting ventricular rates in pts with established AFib. Three options are available for acute treatment of AFlut: rapid atrial pacing, DC cardioversion or administration of propafenone (600 mg oral) or flecainide (300 mg oral).

Zusammenfassung

In der Intensiv-und Notfallmedizin sind in speziellen Situationen oft schnelle diagnostische Maßnahmen und therapeutische Interventionen notwendig. Tachykardien mit schmalem QRS-Komplex (S-QRS-T) sind durch eine Herzfrequenz > 100/min und eine QRS-Breite <0,12 s definiert. S-QRS-T sind typisch für Sinus-Tachykardien (ST), atriale Tachykardien (AT), AV-Knoten-Reentry-Tachykardien (AVNRT), „circus movement“ Tachykardien bei akzessorischen Leitungsbahnen (CMT), bei Vorhofflattern (VH-Flat) und Vorhofflimmern (VH-Flim). Eine systematische EKG-Analyse mit Beurteilung von spontanem AV-Block, QRS-Alternans, P-Wellen Lokalisation und P-Wellen Morphologie erlauben eine Identifikation von Tachykardiemechanismus und -ursprungsort. Bei S-QRS-T mit instabiler Hämodynamik sollte sofort eine elektrische Kardioversion durchgeführt werden. Bei stabilen Kreislauf-Verhältnissen sind vagale Maneuver (Valsalva, Karotis-Druck-Massage) therapeutische Maßnahmen der ersten Wahl. Bei Ineffektivität sollten medikamentöse Interventionen erfolgen: Bei ST sind Betablocker (Metoprolol 5–15 mg i.v.) indiziert, bei AT und AVNRT sollten intial Adenosin (6–18 mg als Bolus i.v.) oder Verapamil (5–10 mg i.v.) appliziert werden. Bei CMT ist Ajmalin (50–100 mg i.v.) besonders effektiv. Bei Ineffektivität der medikamentösen Therapie muss die sekundäre elektrische DC-Kardioversion erfolgen. Bei VH-Flim muss therapeutisch zwischen Arrhythmieter-minierung oder Frequenzverlangsamung unterschieden werden: Für die Akuttherapie von tachykardem VH-Flim (Terminierung von VH-Flim) kommt vor allem die elektrische Kardioversion (Erfolgsrate bis zu 90%) in Betracht oder die medikamentöse Konversion mit Propafenon (600 mg oral), Flecanid (300 mg oral) oder Sotalol (80–160 mg oral). Die Frequenzverlangsamung bei persistierendem VH-Flim kann durch Verapamil (5–10 mg i.v.) und/oder Digoxin (0,4 mg i.v.) erreicht werden. Akutmaßnahmen zur Terminierung von VH-Flat sind vor allem die transvenöse rechtsatriale Überstimulation oder alternativ die elektrische DC- oder medikamentöse Kardioversion mit Propafenon (600 mg oral) oder Flecainid (300 mg).

This is a preview of subscription content, log in via an institution.

Chapter
USD   29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD   49.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD   84.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Learn about institutional subscriptions

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

Literatur

  1. Aboaf AP, Wolf PS (1996) Paroxysmal atrial fibrillation: a common but neglected entity. Arch Intern Med 156:362–367

    Article  PubMed  CAS  Google Scholar 

  2. Akhtar M (1984) Supraventricular tachycardias. Electrophysiologic mechanisms, diagnosis, and pharmacologic therapy. In: Josephson ME, Wellens HJJ (Hrsg) Tachycardias: Mechanism, Diagnosis, Treatment. Lea & Febiger, Philadelphia, S 137–169

    Google Scholar 

  3. Atie J, Brugada P, Brugada J, Smeets JLRM, Cruz FES, Peres A, Roukens MP, Wellens HJJ (1990) Clinical and electrophysiologic characteristics of patients with antidromic circus movement tachycardia in the Wolff-Parkinson-White syndrome. Am J Cardiol 66:1082–1091

    Article  PubMed  CAS  Google Scholar 

  4. Basta MB, Klein GJ, Yee R, Krahn A, Lee J (1997) Current role of pharmacologic therapy for patients with paroxysmal supraventricular tachycardia. In: Scheinman MM (Hrsg) Cardiology clinics — Advances in supraventricular tachycardia. WB Saunders Company, Philadelphia, S 587–597

    Google Scholar 

  5. Bauernfeind RA, Amat-Y-Leon F, Dhingra RC et al (1979) Chronic nonparoxysmal sinus tachycardia in otherwise healthy persons. Ann Intern Med 91:702–710

    PubMed  CAS  Google Scholar 

  6. Camm J, Ward D, Spureil R (1980) Response of atrial flutter to overdrive atrial pacing and intravenous disopyramide phosphate singly and in combination. Br Heart J 44:240–246

    Article  PubMed  CAS  Google Scholar 

  7. Capucci A, Boriani G, Botto GL et al (1994) Conversion of recent-onset atrial fibrillation by a single oral loading dose of propafenone. Am J Cardiol 74:503–505

    Article  PubMed  CAS  Google Scholar 

  8. Capucci A, Lenzi T, Boriani G et al (1992) Effectiveness of loading oral flecainide for converting recent-onset atrial fibrillation to sinus rhythm in patients without organic heart disease or with only systemic hypertension. Am J Cardiol 70:69–72

    Article  PubMed  CAS  Google Scholar 

  9. Chen SA, Tai CT, Chiang CE, Chang MS (1997) Role of the surface electrocardiogram in the diagnosis of patients with supraventricular tachycardia. In: Scheinman MM (Hrsg) Cardiology clinics — advances in supraventricular tachycardia. WB Saunders Company, Philadelphia, S 539–565

    Google Scholar 

  10. Chen SA, Chiang CE, Yang CL et al. Sustained atrial tachycardia in adult patients: electrophysiological characteristics, pharmacological response, possible mechanisms, and effects of radiofrequency ablation. Circulation 90:1262–1278

    Google Scholar 

  11. Delia Bella P, Brugada P, Talajic M, Lemery R, Torner P, Lezaun R, Durgernier T, Wellens HJJ (1991) Atrial fibrillation in patients with an accessory pathway: importance of the conduction properties of the accessory pathway. J Am Coll Cardiol 17:1352–1356

    Article  Google Scholar 

  12. Ellenbogen KA, Clemo HF, Stambler BS et al (1996) Efficacy of ibutilide for termination of atrial fibrillation and flutter. Am J Cardiol 78(Suppl. 8A):42–45

    Article  PubMed  CAS  Google Scholar 

  13. Falk RH (1996) Pharmacologie control of heart rate in atrial fibrillation. In: Dimarco JP (Hrsg) Cardiology Clinics — atrial fibrillation. WB Saunders Company, Philadelphia, S 521–542

    Google Scholar 

  14. Farré J, Wellens HJJ (1981) The value of the electrocardiogram in diagnosing site of origin and mechanism of supraventricular tachycardia. In: Wellens HJJ, Kulbertus HE (Hrsg) What’s new in electrocardiography. Martinus Nijhoff, The Hague, S 131–171

    Chapter  Google Scholar 

  15. Frank G, Baumgart D, Klein H, Luhmer I, Lowes D, Kallfelz HC, Borst HG (1987) Ektope atriale Tachykardie: Chirurgische Therapie (Fallbericht und Literaturübersicht). Z Kardiol 76:118–123

    PubMed  CAS  Google Scholar 

  16. Gomes JA, Winters L, Ip J, Tepper D, Kjellgren O (1993) Identification of patients with high risk of arrhythmic mortality. Role of ambulatory monitoring, signal-averaged ECG, and heart rate variability. In: Akhtar M (Hrsg) Cardiology Clinics — cardiac arrhythmias and related syndromes. WB Saunders Company, Philadelphia, S 55–63

    Google Scholar 

  17. Green M, Heddle B, Dassen W (1983) Value of QRS alternation in determining the site of origin of narrow QRS supraventricular tachycardia. Circulation 68:368–373

    Article  PubMed  CAS  Google Scholar 

  18. Josephson ME, Wellens HJJ (1990) Differential diagnosis of supraventricular tachycardia. In: Scheinman MM (Hrsg) Cardiology Clinics — supraventricular tachycardia. WB Saunders Company, Philadelphia, New York, S 411–442

    Google Scholar 

  19. Jung F, DiMarco JP (1996) Antiarrhythmic drug therapy in the treatment of atrial fibrillation. In: DiMarco JP (Hrsg) Cardiology Clinics — atrial fibrillation. WB Saunders Company, Philadelphia, S 507–520

    Google Scholar 

  20. Kalbfleisch SJ, El-Attassi R, Calkins H et al (1993) Differentiation of paroxysmal narrow QRS complex tachycardias using the 12-lead electrocardiogram. J Am Coll Cardiol 21:85–89

    Article  PubMed  CAS  Google Scholar 

  21. Kaiman J, Olgin J, Saxon L et al Electrocardiographic and electrophysiologic characterization of atypical atrial flutter in man: use of activation and entrainment mapping and implications for catheter ablation. J Cardiovasc Electrophysiol 8:121–144

    Google Scholar 

  22. Kaiman JM, Lee RJ, Fisher WG et al (1994) Radiofrequency catheter modification of sinus node function guided by intracardiac echocardiography. Circulation 90:1–270 (Abstract)

    Article  Google Scholar 

  23. Kay GN, Pressley JC, Packer DL et al (1987) Value of the 12-lead electrocardiogram in discriminating atrioventricular nodal reciprocating tachycardia from circus movement atrioventricular tachycardia utilizing a retrograde accessory pathway. Am J Cardiol 59:296–300

    Article  PubMed  CAS  Google Scholar 

  24. Lee RJ, Kaiman JM, Fitzpatrick AP et al (1995) Radiofrequency catheter modification of the sinus node for „inappropriate“ sinus tachycardia. Circulation 92:2919–2928

    Article  PubMed  CAS  Google Scholar 

  25. Masoudi FA, Goldschlager N (1997) The medical management of atrial fibrillation. In: Scheinman MM (Hrsg) Cardiology clinics — advances in supraventricular tachycardia. WB Saunders Company, Philadelphia, S 689–719

    Google Scholar 

  26. Morillo CA, Klein GJ, Thakur RK et al (1994) Mechanism of „inappropriate“ sinus tachycardia: Role of sympathovagal balance. Circulation 90:873–877

    Article  PubMed  CAS  Google Scholar 

  27. Obel OA, Camm AJ (1997) Supraventricular tachycardia. ECG diagnosis and anatomy. Eur Heart J 18(Suppl. C):2–11

    Article  Google Scholar 

  28. Pietersen AH, Andersen ED, Sandoe E (1992) Atrial fibrillation in the Wolff-Parkinson-White syndrome. Am J Cardiol 70:38A–43A

    Article  PubMed  CAS  Google Scholar 

  29. Podrid PJ (1995) Atrial fibrillation. In: Parmley WB, Chatterjee K (Hrsg) Cardiology. Lippincott-Raven, Philadelphia, S 1–30

    Google Scholar 

  30. Rankin AC, Brooks R, Ruskin JN (1992) Adenosine and the treatment of supraventricular tachycardia. Am J Med 92:655–664

    Article  PubMed  CAS  Google Scholar 

  31. Sager PT, Bhandari AK (1991) Narrow complex tachycardias. Differential diagnosis and management. In: Shah PK (Hrsg) Cardiology Clinics — acute cardiac care. WB Saunders Company, Philadelphia, S 619–640

    Google Scholar 

  32. Stroke Prevention in Atrial Fibrillation Investigators (1992) Predictors of thromboembolism in atrial fibrillation. I. Clinical features of patients at risk. Ann Intern Med 116:1–5

    Google Scholar 

  33. Tang CW, Scheinman MM, Van Hare GF et al (1995) Use of P wave configuration during atrial tachycardia to predict site of origin. J Am Coll Cardiol 26:1315–1324

    Article  PubMed  CAS  Google Scholar 

  34. The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators (1990) The effect of low dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation. N Engl J Med 323:1505–1511

    Article  Google Scholar 

  35. Trappe HJ (2000) Diagnosis and treatment of tachycardias. In: Vincent JL (Hrsg) 2000 — Yearbook of intensive care and emergency medicine. Springer Verlag, Berlin Heidelberg New York, S 638–648

    Google Scholar 

  36. Trappe HJ (1998) Lebensgefährliche Tachyarrhythmien. Intensiv-und Notfallmedizin 23:13–26

    Google Scholar 

  37. Trappe HJ, Paul T, Pfitzner P, Lichtlen PR (1994) Ablation einer permanenten linksatrialen ektopen Tachykardie durch Hochfrequenzenergie. Z Kardiol 83:582–588

    PubMed  CAS  Google Scholar 

  38. Trappe HJ (1998) Atriale Tachykardien. Pathophysiologie — Klinik — Diagnostik — Therapie. In: Gonska BD (Hrsg) Invasive Elektrophysiologie — Lehrbuch und Atlas. Thieme Verlag, Stuttgart, S 147–162

    Google Scholar 

  39. Trappe HJ, Paul T, Pfitzner P (1996) Mehrjährige therapierefraktäre Dauertachykardie bei einer 40-jährigen Frau. Internist 37:392–397

    PubMed  CAS  Google Scholar 

  40. Trappe HJ (1997) Akuttherapie supraventrikulärer Tachykardien: Adenosin oder Ajmalin? Intensivmed 34:452–461

    Article  Google Scholar 

  41. Vlay SC (1995) Clinical recognition of cardiac arrhythmias. In: Vlay SC (Hrsg) A practical approach to cardiac arrhythmias. Little, Brown and Company, Boston, S 54–76

    Google Scholar 

  42. Waldo A, Carlson M, Biblo L et al (1993) Entrainment techniques for mapping atrial and ventricular tachycardias. J Cardiovasc Electrophysiol 6:201–216

    Google Scholar 

  43. Waldo AL (1990) Clinical evaluation in therapy of patients with atrial fibrillation or flutter. In: Scheinman MM (Hrsg) Cardiology Clinics — supraventricular tachycardia. WB Saunders Company, Philadelphia, S 479–490

    Google Scholar 

  44. Waldo AL, Mackall JA, Biblo LA (1997) Mechanisms and medical management of patients with atrial flutter. In: Scheinman MM (Hrsg) Cardiology clinics — advances in supraventricular tachycardia. WB Saunders Company, Philadelphia, S 661–676

    Google Scholar 

  45. Weismüller P, Kattenbeck K, Heinroth KM, Ranke C, Trappe HJ (2000) Terminierung supraventrikulärer Tachykardien durch Adenosin — Vergleich der Wirkung von 12 mg und 18 mg. Dtsch Med Wschr 125 (im Druck)

    Google Scholar 

  46. Wellens HJJ, Gorgels APM, Rodriguez LM, Vos MA, Smeets JLRM (1993) Supraventricular tachycardias: mechanisms, electrocardiographic manifestations, and clinical aspects. In: Josephson ME, Wellens HJJ (Hrsg) Tachycardias: Mechanisms and management. Futura Publishing Company, Mount Kisco, New York, S 121–147

    Google Scholar 

  47. Wellens HJJ, Atie J, Penn OC et al (1990) Diagnosis and treatment of patients with accessory pathways. Cardiol Clin 8:503–521

    PubMed  CAS  Google Scholar 

  48. Wellens HJJ, Conover MB (1992) The ECG in emergency decision making. WB Saunders Company, Philadelphia, S 73–103

    Google Scholar 

  49. Wellens HJJ, Durrer D (1973) Effect of digitalis on atrioventrcular conduction and circus movement tachycardias in patients with the Wolff-Parkinson-White syndrome. Circulation 47:1229–1233

    Article  PubMed  CAS  Google Scholar 

  50. Zipes DP, Wellens HJJ (1998) Sudden cardiac death. Circulation 98:2334–2351

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Medizinische Klinik II (Schwerpunkt Kardiologie und Angiologie), Universitätsklinik Marienhospital Ruhr-Universität, Bochum Hölkeskampring 40, 44625, Herne, Germany

    Prof. Dr. med. H.-J. Trappe & P. Weismüller

  2. Abteilung Kardiologie Akademisches Hospital Maastricht, Universität Limburg, Holland

    L.-M. Rodriguez & J. L. R. M. Smeets

Authors
  1. Prof. Dr. med. H.-J. Trappe
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. P. Weismüller
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. L.-M. Rodriguez
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. J. L. R. M. Smeets
    View author publications

    You can also search for this author in PubMed Google Scholar

Editor information

Editors and Affiliations

  1. Universitätsklinik Marienhospital Herne Medizinische Klinik II, Ruhr-Universität Bochum, Hölkeskampring 40, D-44625, Herne, Germany

    H.-J. Trappe

  2. Städtisches Krankenhaus Hildesheim Medizinische Klinik I, Akademisches Lehrkrankenhaus der Medizinischen Hochschule Hannover, Weinberg 1, D-31134, Hildesheim, Germany

    H.-P. Schuster

Rights and permissions

Reprints and permissions

Copyright information

© 2001 Springer-Verlag Berlin Heidelberg

About this chapter

Cite this chapter

Trappe, HJ., Weismüller, P., Rodriguez, LM., Smeets, J.L.R.M. (2001). Diagnostik und Therapie von Tachykardien mit schmalem QRS-Komplex. In: Trappe, HJ., Schuster, HP. (eds) Die Notfalltherapie bei akuten Herzrhythmusstörungen. Steinkopff, Heidelberg. https://doi.org/10.1007/978-3-642-57631-7_3

Download citation

  • DOI: https://doi.org/10.1007/978-3-642-57631-7_3

  • Publisher Name: Steinkopff, Heidelberg

  • Print ISBN: 978-3-7985-1294-8

  • Online ISBN: 978-3-642-57631-7

  • eBook Packages: Springer Book Archive

Publish with us

Policies and ethics

Search

Navigation