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PVCs triggering sinus tachycardia or concealed pathway
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PVCs triggering sinus tachycardia or concealed pathway


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.
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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.
13 Comments
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Pluto:Thanks for posting those Q.s.

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
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hello i am 28 male i have been having wierd discomfort around my left pectoral area.. like preasure, i take atenolol 25 mg every other day now and i also take 100mg zoloft. i also have a like bounding pulse in neck area both sides, i can see it, is this normal? i also have a abdominal pulsation that is visable, i am not skinny i am 180 5-7, i have had the ech,ekg,holter,event tests about 10 mos ago. was told everything okay i guess except for sinus tachy, is there anything i should pursue, at the time of all my trouble i had no insurance so always wonder if they really did all the tests needed. i now have insurance. i also take glyconutirents., just started saturday. please help!! i was at the mall today and had this faintiy feeling and check my blood preasure with my monitor i have and was high 155-95..pulse 100. i use olive oil also extra virgin, a pop maybe once a week, mostly water.
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Avatar_n_tn
Hi there
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
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Hear what you're saying "why take the risk" and agree to a large extent however I do have a friend down the road whose life was a misery with svt and eventually she had an ep study which revealed two accessory pathways in her heart.  2 ablations later she is totally cured with not a single extra beat in over 7 years. Doesn't that sound like bliss?!!
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,
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Hi, I am new to the site and wanted to ask the doctor a question.  I am seeing a specialist for HCM but thought the forum and hopefully the doctor could answer some of my questions.  I had a cardiac MRI last week and the results are greek to me.  Says my maximal septal thickness in the four chamber view is 2.9 cm.  There is a lot more to it but my biggest question is why I would have extensive septal and anterobasal scarring?  I am a 27 yr old female and have no history of cardiomyopathy in the family.  My left atrium is moderately to severly dilated and right atrium is mildly so.  If anyone has any experience with this or has any questions I'm leaving out to properly answer me, please let me know.  I see that many people have been helped on this site and I am very curious to see what all this means.  I will be seeing the specialist again soon as well.  Thank you,  J2112
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I started having pvc's in 1964.  Had them for forty years now.  I would have an attack every so often and go for months, even a year or so before more violent attacks along with afib.  The dadgummed things never quit dogging the daylights out of me and still hit me to some extent everyday.  Some days all I can do is lounge around and hope they will go away and just 'ride 'em out'.  Makes me feel like they are going to 'take me out'.  I am going to have a touch-up ablation for afib that is still bothering me after my pva this past March and pvc's will be addressed at that time as well.

They DO NOT ever go away or get better for good, just keep struggling to cope.

Glenn Camp
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Avatar_n_tn
Blimey!!  That was some answer to Pluto's question. Thank you indeed!  If only I was clever enough to fully understand it:-).  This really is a brilliant site.
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hi,
when u say u had a high resting heart rate when u were younger, how old were you??
thanks,
pan
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My WPW (concealed pathway) manifested as wide QRS with a moving axis.  It took an EP study to differentiate between VT and PSVT.  I am no expert, and am repeating what my family doctor told me (not my EP), but I understand that the concealed pathway creates a PSVT that creates a wide QRS.
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By the way, these catheterizations aren't so bad.  You could always do the EP study without the ablation to find out more, or be put out altogether for the EP study. The cath was only in for 7 minutes on my angiogram.  I felt next to nothing, including no affect of valium (I could swear they forgot to give it to me).

I wish I had had angio prior to ablation.  In the end though, angio results were normal.  And as an added benefit, I also know how my coronary arteries are doing.
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Avatar_n_tn
WPW,

You quoted:

"My WPW (concealed pathway) manifested as wide QRS with a moving axis. It took an EP study to differentiate between VT and PSVT. I am no expert, and am repeating what my family doctor told me (not my EP), but I understand that the concealed pathway creates a PSVT that creates a wide QRS."

I'm fascinated that it took an EP study to distinguish between VT and PSVT. It would accordingly appear that the two arrythymias can present almost identically on rhythym strips..... but is this only the case where a Concealed Accessory Pathway is present??

I somtimes get runs of palps (daytime & always at rest) as follows: a fast regular beat of 180-ish for a few seconds followed by a couple of heavy thuds interspersed with longish pauses, followed by a few more secs of the fast regular beat, then the whole thing resolves itself with a pause and THUMP.... and NSR. I have had 5 episodes of AF during the last 5 yrs too - all nocturnal, a few hrs duration, and self-converting with no meds. Interestingly, and bearing in mind the aforementioned, on the one occasion when I awoke to find myself going into AF (as opposed to awaking fully in it), I noticed that my heart was switching between 5 to 10-ish second periods of a fast regular rhythym and AF before finally (after 30-40 seconds or so) settling into AF. Almost as if the AF was kinda forced/propelled into being by the fast regular rhythym. I really do wonder just how many folks out there (like me) who get such runs of palps actually do so owing to the existence of a CAP??

Good to converse with you folks via this forum,

Mike
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big mick,

regarding the wide qrs question --- actually, I don't know.  Think I am going to need to ask the doc on that one.  There is also the emedicine.com web site if you have ever tried that.  I highly recommend the article on WPW there.  It seems very thorough.  However, I can think of one case of orthodromic tachy that isn't in there... Mine!!

I am also unclear on the AF question as it applies to me as well.  Emedicine indicates AF is with 15-30% of people with WPW. But how does one experience AF?  Does one feel anxiety and and slightly irregular pulse?  Fluttering chest sensations? How do you know when AF is acting up?

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