Occurs in the settings of coronary artery disease, congestive heart failure, cardiac surgery, catecholamine ingestion, digoxin toxicity, and alcohol dependency.
Symptoms and signs include palpitations, fatigue, pre-syncope/syncope, chest pain.
ECG shows a regular atrial tachycardia with P-wave morphology different from that in sinus tachycardia.
Treatment consists of a trial of adenosine, withdrawal of the causative agent, or treatment of the underlying cause. For sustained tachycardias, cardiology consultation, class Ia/Ic or III anti-arrhythmic agents, and ablative therapy are appropriate.
Complications include haemodynamic instability and congestive heart failure.
Focal atrial tachycardia (focal AT) is characterised as a rapid regular rhythm arising from a discrete area within the atria. It occurs in a wide range of clinical conditions, including catecholamine excess, digoxin toxicity, paediatric congenital heart disease, and cardiomyopathy. Focal AT is a regular tachycardia and is often confused with other regular supraventricular tachycardias, specifically re-entry tachycardias, sinus tachycardia, and atrial flutter. It may be difficult to diagnose by ECG alone. The diagnosis of focal AT is usually based on ECG, clinical history, and response to interventions such as vagal manoeuvres and adenosine.
History and exam
Key diagnostic factors
- presence of risk factors
- cardiac disease
Other diagnostic factors
- fatigue, weakness
- chest pain
- shortness of breath, cough
- nausea, vomiting
- light-headedness, syncope
- coronary artery disease
- substance misuse (alcohol ingestion/withdrawal, cocaine, amphetamines)
- digoxin toxicity
- exacerbation of chronic lung disease
- previous cardiac surgery to correct congenital heart defects
1st investigations to order
- digoxin level
- theophylline level
- toxicology screen
Investigations to consider
- vagal manoeuvres, adenosine
- thyroid-stimulating hormones
- ambulatory 24-hour (Holter) ECG or event recorder
- electrophysiological study (EPS)
adult: undifferentiated supraventricular tachycardia
adult: focal AT; digoxin excess not suspected
adult: focal AT; digoxin toxicity suspected
adult: sustained or recurrent focal AT
Sarah Stahmer, MD
Department of Emergency Medicine
University of North Carolina
SS declares that she has given lectures regionally and nationally that include paroxysmal atrial tachycardia.
Amal Mattu, MD
Associate Professor of Emergency Medicine
University of Maryland Medical Center
AM declares that he has no competing interests.
Vias Markides, MB(Hons), BS(Hons), MD, FRCP
Royal Brompton & Harefield NHS Trust
Imperial College London
VM declares that he has no competing interests.
- Sinus tachycardia
- AV node re-entry tachycardia
- Atrial flutter
- 2019 ESC guidelines for the management of patients with supraventricular tachycardia
- ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia
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