Case-based MCQ

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The correct answer is A. Supraventricular tachycardias (SVT) include paroxysmal, reentry, or preexcitation tachycardias. Reentry SVTs include AV nodal reentry (AVNRT), atrioventricular reentry, or atrial reentry. Reentry circuits require the presence of at least two different conduction pathways with differential refractory times. It is characterized by an abrupt onset and termination of tachycardia, that distinguishes it from sinus tachycardia, which has gradual changes in rate. It is precipitated by a premature atrial or ventricular contraction or hyperadrenergic state. Other triggers include hyperthyroidism and stimulants, including caffeine, drugs, and alcohol. This patient has supraventricular tachycardia (SVT) likely related to atrioventricular nodal reentrant tachycardia (AVNRT) and he has no concerning symptoms. The ECG shows a regular, fast rhythm with absent P waves and a narrow QRS complex. Unstable patients require immediate synchronized cardioversion. Stable patients, such as the patient above, should first undergo vagal maneuvers. Some common vagal maneuvers include holding your breath and bearing down (Valsalva maneuver), coughing, gagging, and immersing your face in ice-cold water. If vagal maneuvers are unsuccessful, adenosine is used both diagnostically and therapeutically. Adenosine transiently blocks the AV-node and allows the circuit to “reset.” ⚠Choice B is not correct: Adenosine is very short acting and can be used if vagal maneuvers fail to terminate the arrhythmia. ⚠Choice C is not correct: Metoprolol would also be considered if the above measures failed. ⚠Choice D is not correct: Digoxin would also inhibit the AV node but has more potential side effects than the other medications and is rarely used for this purpose. ⚠Choice E is not correct: Cardioversion would be reserved for hemodynamic instability including hypotension, heart failure, or angina. Summarized Points: This patient has SVT likely related to AVNRT and he has no concerning symptoms. The initial attempts at termination should use vagal maneuvers such as the Valsalva maneuver.

A 40-year-old man is evaluated for palpitations in the emergency department. He has had these symptoms several times over the past year but this episode is worse. He denies any associated chest pain, lightheadedness, or syncope. He denies any history of medical problems and takes no medications. Examination reveals an adult male in no significant distress. Cardiac examination is significant for regular tachycardia with no jugular venous pressure elevation. Lungs are clear without crackles or wheezing. There is no lower extremity edema. ECG shown below. What is the best intervention at this point? A. Valsalva maneuver B. Adenosine C. Metoprolol D. Digoxin E. Cardioversion

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