Atrioventricular Nodal Reentrant Tachycardia (AVNRT)

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LITFL | Medical Specialty | Cardiology | AVNRT for two

AVNRT for two

by Mike Cadogan

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A 56 year old year old woman presents to the Emergency Department with a referral from her General
Practitioner for assessment and management of severe tachycardia and possible myocardial

infarction following a sudden onset of palpitations. Objectively she was found to have a regular
tachycardia with no overt signs of cardiovascular compromise
Case Study
The patient described experiencing the sudden onset of palpitations whilst cleaning at 10:30am that
morning. She stated that the palpitations came on without warning and had not gone away after she
ceased cleaning to lie down they were regular and extremely fast. There were no associated
symptoms of shortness of breath, dizziness or chest pain. Five hours later, upon her presentation to
the Emergency Department, the rapid heart rate is still continuing.
She describes to you a ve year history of occasional episodes of suddenly increased heart rate, but
in all cases, they self-resolved within one minute and she did not seek medical investigation or
treatment.
On examination in the emergency department, her heart rate is 160bpm and regular, RR 20bpm and
BP 134/75. She was apyrexial and saturating at 97% on room air. Cardiovascular and respiratory
examination revealed no abnormalities aside from the tachycardia.
Her ECG on arrival is shown below:

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Atrioventricular Nodal Reentrant Tachycardia (AVNRT)

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On the history, examination and ECG ndings, the patient was diagnosed with Fast-Slow AVNRT
(Uncommon Atrioventricular Nodal Reentrant Tachycardia) and successfully treated with 6mg of
adenosine.

What is AVNRT?
Atrioventricular Nodal Reentrant Tachycardia is a type of supraventricular tachycardia (ie it originates
above the level of the Bundle of His) and is the commonest cause of palpitations in patients with hearts
exhibiting no structurally abnormality.

Clinical Features of AVNRT

AVNRT is typically paroxysmal and may occur spontaneously in patients or upon provocation with
exertion, coffee, tea or alcohol. It is more common in women than men (~75% of cases occurring in
women) and may occur in young and healthy patients as well as those suffering chronic heart
disease.
Patients will typically complain of the sudden onset of rapid, regular palpitations. The patient may
experience a brief fall in blood pressure causing presyncope or occasionally syncope.
If the patient has underlying coronary artery disease the patient may experience chest pain similar to
angina (tight band around the chest radiating to left arm or left jaw).
The patient may complain of shortness of breath, anxiety and occasionally polyuria due to elevated
atrial pressure releasing atrial natriuretic peptide.
The tachycardia typically ranges between 140-280 bpm and is regular in nature. It may cease
spontaneously (and abruptly) or continue indenitely until medical treatment is sought.
The condition is generally well tolerated and is rarely life threatening in patients with pre-existing
heart disease.

Pathophysiology and types of AVNRT

AVNRT is caused by a reentry circuit in or around the AV node.
The circuit is formed by the creation of two pathways forming the re-entrant circuit, namely the slow
and fast pathways.
The fast pathway is usually anteriorly situated along septal portion of tricuspid annulus with the slow
pathway situated posteriorly, close to the coronary sinus ostium.
Sustained reentry occurs over a circuit comprising the AV node, His Bundle, ventricle, accessory
pathway and atrium.
The various forms of AVNRT can be described in terms of ECG appearance such as R-P intervals or

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The descriptive terminology regarding AVNRT classication can be confusingand I am still confused!
Slow-Fast AVNRT (Common AVNRT)
Accounts for 80-90% of AVNRT
Associated with Slow AV nodal pathway for anterograde conduction and Fast AV nodal pathway for
retrograde conduction.
The retrograde P wave is obscured in the corresponding QRS or occurs at the end of the QRS
complex as pseudo r or S waves
ECG:
P waves are often hidden being embedded in the QRS complexes.
Pseudo r wave may be seen in V1
Pseudo S waves may be seen in leads II, III or aVF.
In most cases this results in a typical SVT appearance with absent P waves and tachycardia

AVNRT Slow-Fast

Cardiac rhythm strips demonstrating (top) sinus rhythm and (bottom) paroxysmal supraventricular
tachycardia. The P wave is seen as a pseudo-R wave (circled in bottom strip) in lead V1during
tachycardia. By contrast, the pseudo-R wave is not seen during sinus rhythm (it is absent from circled
area in top strip). This very short ventriculoatrial time is frequently seen in typical Slow-Fast
Atrioventricular Nodal Reentrant Tachycardia.
Fast-Slow AVNRT (Uncommon AVNRT)
Accounts for 10% of AVNRT
Associated with Fast AV nodal pathway for anterograde conduction and Slow AV nodal pathway for
retrograde conduction.
The retrograde P wave appears after the corresponding QRS
ECG
QRS -P-T complexes
P waves are visible between the QRS and T wave

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Slow-Slow AVNRT (AtypicalAVNRT)

1-5% AVNRT
Associated with Slow AV nodal pathway for anterograde conduction and Slow left atrial bres
approaching the AV node as the pathway for retrograde conduction.
ECG: Tachaycardia with a P-wave seen in mid-diastole effectively appearing before the QRS
complex
Confusing as a P wave appearing before the QRS complex in the face of a tachycardia might honestly
be read as a sinus tachycardia..

Schematic of typical atrioventricular nodal reentry.

Left Panel: Anterograde conduction from the atrium (ATR) to the ventricle (VTR) over both slow and
fast pathways. The ventricle is activated initially in sinus rhythm by the fast pathway.
Centre Panel: The effect of a premature atrial complex (PAC). Although the fast pathway conducts
rapidly, it repolarizes slowly. In this hypothetical scenario, the fast pathway is refractory to the PAC,
allowing the PAC to proceed via the slow pathway, which has a shorter refractory period.
Right Panel: Anterograde conduction of the PAC occurs via the slow pathway, with subsequent
recovery of the fast pathway. These conditions allow retrograde conduction into the atrium via the
fast pathway, thereby creating the rst beat of typical slow-fast atrioventricular nodal reentrant

tachycardia.
Investigations
The ECG will typically show a tachycardia of 140-280 bpm with normal and regular QRS complexes. There
will be either
No visible P-waves (hidden within the QRS complex) or
P-waves immediately before the QRS or
P-waves immediately after the QRS complex
For recurrent episodes of palpitations, a Holter monitor and EPS may be useful in identifying rhythms
typical of AVNRT. An echocardiogram may be useful in evaluating for structural heart disease and
electrophysiological studies may be necessary if considering ablative therapy. Blood tests that may be
appropriate in patients experiencing palpitations include cardiac markers (to investigate for myocardial
infarction), urea and electrolytes (to identify imbalances in potassium, magnesium or calcium) or thyroid
function tests (hyperthyroidism may trigger AVNRT or other arrhythmias).
Management
Patients may be instructed to undertake vagal manoeuvres upon the onset of symptoms which can be
effective in stopping the AVNRT. This may involve carotid sinus massage or valsalva manoeuvres, which

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Adenosine, beta-blockers or calcium channel blockers can suppress an AVNRT event by blocking or
slowing the AV node. Other second-line therapies may include amiodarone or flecainide.
Cardioversion is rarely used on patients with AVNRT, usually when the tachycardia is refractory to
other medical therapies or the tachycardia is causing haemodynamic instability (falling blood
pressure, development of heart failure etc.)
Radiofrequency catheter ablation can be offered to patients with frequent attacks for whom medical
therapy isnt appropriate in the long term, and can be curative.

Useful reading

Mayo Clinic Proceedings

AV nodal reentrant tachycardia Wikipedia

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Filed Under: Cardiology, Clinical Case, ECG, Education, Emergency Medicine, Investigation, Medical Specialty
Tagged With: Atrioventricular Nodal Reentrant Tachycardia, AVNRT, ECG, QRSPT, SVT

About Mike Cadogan

Emergency physician with a passion for medical informatics and medical
education. Co-founder of HealthEngine. Asynchronous learning #FOAMed
evangelist | @sandnsurf | + Mike Cadogan | LinkedIn

Comments
stand says
January 4, 2010 at 1:55 am
Thanks for this post. I really love ECG but could hardly understand AVNRT types; this post
denitely pushed me to read more. Thanks also for the Mayo Clinic link.
Great explanation here too in this book: http://bit.ly/6Cv6Kz
The bottom line is AVNRT is treated the same way regardless of the type (but I still like knowing
the types).
Reply

athikitie says

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Breathe Right nasal strips are designed to help, easy to open nasal passages for interim relief for
stuffy nose. Do you need it? Go to http://www.breatherightnasalstrips.com/
Reply

Eleonard says
October 22, 2010 at 4:14 am
I was diagnose and treated with ablation surgery in 2000 for AVNRT, at the time I was told that
this was passed onto me from another female in my family, and if I were ever to have a female
child I would pass this onto them as well. Can you tell me if this is true? I am now 16 weeks
pregnant and no one seems to know anything about AVNRT
Reply

Zoltan says
February 13, 2012 at 9:16 am
Hi,
Good summary and case. I think though, the 1st tachycardia ECG depicts a typical slow-fast
AVNRT, rather than an atypical fast-slow one; the VA time is very short retrograde Ps just after the
QRS.
Reply

Francis says
August 19, 2012 at 2:14 pm
I agree with Zoltan regarding the rst ECG, should be Slow-fast? An electrophysiologic
examination may need to tell the truth.
Reply

Trackbacks
The ECG Library will leave you feeling ecgstatic! says:
January 10, 2012 at 3:39 pm
[...] AVNRT [...]
Strip 57 StripTease says:
February 14, 2013 at 1:00 pm
[...] are often AV node reentry rhythms where a slow and fast pathway are allowed to form a loop by a PAC
or PVC resetting the fast pathway so that the slow pathway is able to auto-cycle the [...]

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