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Heart Disease (Expert Forum)
PVCs triggering sinus tachycardia or concealed pathway
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PVCs triggering sinus tachycardia or concealed pathway
by pluto, Jul 19, 2004 12:00AM
Thanks for taking my questions as always.
I am an off and on PVC sufferer, i usualy get an attack about every 3-4 years since 1992 that last from weeks to 5-6 months, then disappear only to return again when you least expect, of course i always get the odd thump on a daily basis , but nothing to speak of.
My questions are, i had a PVC in 1992 that triggered a sinus tachycardia(documented on ecg at the time with PVCs occuring along with tachycardia at a rate of about 160-170bpm.) I know it is unusual for PVCs to be occuring along with true PSVT, unless it is anxiety tachycardia related. Do you think it is possible that a concealed accessory pathways could actually be the cause? I have PVCs that trigger no tachycardia and then PVCs that trigger a rapid tachycardia in 150-170- bpm range , doesn't last any longer than about 15 minutes, like I said documented as sinus tachycardia with PVCs on an ECG at the time, told it was nothing to worry about, the PVCs usually stick around sometimes after the tachycardia is gone. From what I understand tachycardia from concealed accessory pathways are almost always triggered by PVCs and it conducts in a retrograde manner, thus it does not cause ventricular preexcitation, at least in the vast majority of cases, even though there can be a rapid ventricular response. My resting ECG are normal and stress test are normal. Are concealed pathways usually only discovered in an EP study? Can a PSVT from a concealed pathway masquerade as sinus tachycadia?
I take atenolol 100mg individed doses, have a few PVCs, no tachycardia, Thanks.
Doctor's Answer
by CCF-M.D.-MJM, Jul 19, 2004 12:00AM
Hi Pluto,
These are some pretty advanced questions......chapters are written to address them. I will do my best
1. Do you think it is possible that a concealed accessory pathway could actually be the cause?
I agree that frequent PVCS and paroxysmal supraventricular tachycardia (PSVT) usually do not occur in the same host, but it is possible. If a premature ventricular complex (PVC) immediately precedes the initiation of the SVT, it is likely that the cause is a re-entry loop, often through an accessory pathway. The key to initiating a reentry loop has everything to do with the timing of the PVC -- it has to be perfect. That is why most PVCs would not cause the SVT, but occasionally one sneaks in. For those that don't know, some accessory pathways are seen on the EKG and are said to be manifest. When the accessory pathway is electrocardiographically silent (not apparent on the EKG), it is said to be "concealed." In pluto's case it may be concealed because it is not seen on his baseline or exercise EKG.
You said they called it sinus tachycardia. If were truly sinus (ie p waves with the same morphology as your baseline EKG), this would unlikely be caused by a concealed pathway. It could still be caused by re-entry loop, possibly around a scar. The key is the initiation and termination.
Anxiety related tachycardia usually does not start abruptly. It has a warm up period, sometimes only a few beats, where you can see a clear acceleration in the rate from beat to beat until it stabilizes at a new rate. Then it slows down gradually. Reentry loops usually turn on and turn off, sometimes with a brief pause, but no warm up. The key to answering your question, pluto, is to capture the initiation and termination of the tachycardia. This would either take a holter monitor, event monitor, cellular telemetry (cardionet), or an implantable recording device.
I hope that is relatively clear. This question is usually answered with a chalk board and 30 minutes of discussion.
2. Are concealed pathways usually only discovered in an EP study?
True. Although they are often strongly suspected by the type of arrhythmia being investigated on the EP study. The EP study is needed to prove it.
3. Can a PSVT from a concealed pathway masquerade as sinus tachycardia?
You never want to say never, but this is usually not the case. In most reentry tachycardia the p wave takes a distinct morphology or shape different from the sinus p wave. It is possible that a perfectly positioned scar in the atria could cause a reentry loop that makes p waves similar to sinus.
I hope this helps and thanks for posting.
These are some pretty advanced questions......chapters are written to address them. I will do my best
1. Do you think it is possible that a concealed accessory pathway could actually be the cause?
I agree that frequent PVCS and paroxysmal supraventricular tachycardia (PSVT) usually do not occur in the same host, but it is possible. If a premature ventricular complex (PVC) immediately precedes the initiation of the SVT, it is likely that the cause is a re-entry loop, often through an accessory pathway. The key to initiating a reentry loop has everything to do with the timing of the PVC -- it has to be perfect. That is why most PVCs would not cause the SVT, but occasionally one sneaks in. For those that don't know, some accessory pathways are seen on the EKG and are said to be manifest. When the accessory pathway is electrocardiographically silent (not apparent on the EKG), it is said to be "concealed." In pluto's case it may be concealed because it is not seen on his baseline or exercise EKG.
You said they called it sinus tachycardia. If were truly sinus (ie p waves with the same morphology as your baseline EKG), this would unlikely be caused by a concealed pathway. It could still be caused by re-entry loop, possibly around a scar. The key is the initiation and termination.
Anxiety related tachycardia usually does not start abruptly. It has a warm up period, sometimes only a few beats, where you can see a clear acceleration in the rate from beat to beat until it stabilizes at a new rate. Then it slows down gradually. Reentry loops usually turn on and turn off, sometimes with a brief pause, but no warm up. The key to answering your question, pluto, is to capture the initiation and termination of the tachycardia. This would either take a holter monitor, event monitor, cellular telemetry (cardionet), or an implantable recording device.
I hope that is relatively clear. This question is usually answered with a chalk board and 30 minutes of discussion.
2. Are concealed pathways usually only discovered in an EP study?
True. Although they are often strongly suspected by the type of arrhythmia being investigated on the EP study. The EP study is needed to prove it.
3. Can a PSVT from a concealed pathway masquerade as sinus tachycardia?
You never want to say never, but this is usually not the case. In most reentry tachycardia the p wave takes a distinct morphology or shape different from the sinus p wave. It is possible that a perfectly positioned scar in the atria could cause a reentry loop that makes p waves similar to sinus.
I hope this helps and thanks for posting.
Doc: I too will be most interested in the answers to Pluto's Q.s (and thanks for the great service you provide BTW.).
BM
An EP study I had revealed scar tissue in my right atrium, during the EP study when this area was stimulated by adrenalin my heart rate shot up to 260 bpm, however the cardiologist found to his surprise that when the ventricular area was stiumlated with adrenalin that too set off the atrial tachycardia. I have found on occasions that a couple of pvcs can set off a short bout of atrial tachy. So maybe something like that could be happening to you??
Why not have an EP study? I was terrified of doing it but thanks to valium and the reassurance of a cardiologist and team on hand I got through it fairly well and thus found out what was wrong with my heart. It is helpful to actually know what what the problem is.
Best Wishes, Linda
Basically I wanted to know if what I had was ablatable as for about 5 years I was living a life of sick fear due to the many differing palpitations I was experiencing each and every day. I now know that part of my problem was due to my diminishing levels of estrogen going into menopause and so the commencement of HRT made a staggering difference to me in that it really reduced my palpitations and also took away the unbalanced feeling I had in my chest prior to the HRT. I have topped up my recovery in the last 6 months by taking paroxetine which has also helped enormously in that it has made me feel positive and much less anxious. I was so worried about taking paroxetine as I felt sure it would give me some sort of arrythmia - it hasn't. This tells me for sure how much anxiety provokes our palpitation problem.
HOWEVER, if in the future I am to go back into the palpitation nightmare of a few years ago which has to be a possibility I would definitely go the ablation route, I very nearly went there as it was. I do think it obviously is best not to have an ablation if heart medicines are effective - in my case they only made me worse.
The ablation route needs a lot of thought, no doubt, but it is nice to know it is an option if all else fails.
Best wishes,
They DO NOT ever go away or get better for good, just keep struggling to cope.
Glenn Camp
when u say u had a high resting heart rate when u were younger, how old were you??
thanks,
pan