Focal atrial tachycardia

Last reviewed: August 2019

Last updated: April 2019

Summary

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, presyncope/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 antiarrhythmic agents, and ablative therapy are appropriate.

Complications include hemodynamic instability and congestive heart failure.

Definition

Focal atrial tachycardia (focal AT) is characterized 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, pediatric 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 maneuvers and adenosine.

History and exam

Key diagnostic factors

cardiac disease

Full details

Other diagnostic factors

medications
palpitations
fatigue, weakness
chest pain
shortness of breath, cough
nausea, vomiting
lightheadedness, syncope
rales
edema

Full details

Risk factors

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

Full details

Diagnostic investigations

1st investigations to order

ECG
digoxin level
theophylline level
CXR
electrolytes
toxicology screen

Full details

Investigations to consider

vagal maneuvers, adenosine
thyroid-stimulating hormone
echocardiogram
ambulatory 24-hour (Holter) ECG or event recorder
electrophysiologic study (EPS)

Full details

Treatment algorithm

INITIAL

Contributors

Authors VIEW ALL 

Sarah Stahmer, MD

Associate Professor

Department of Emergency Medicine

University of North Carolina

Chapel Hill

Disclosures

SS declares that she has no competing interests.

Peer reviewers VIEW ALL 

Amal Mattu, MD

Associate Professor of Emergency Medicine

University of Maryland Medical Center

Baltimore

Disclosures

AM declares that he has no competing interests.

Vias Markides, MB(Hons), BS(Hons), MD, FRCP

Consultant Cardiologist

Royal Brompton & Harefield NHS Trust

Imperial College London

London

Disclosures

VM declares that he has no competing interests.

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Focal atrial tachycardia

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

adult: undifferentiated supraventricular tachycardia

adult: focal AT; digoxin excess not suspected

adult: focal AT; digoxin toxicity suspected

child

adult: sustained or recurrent focal AT

Contributors

Authors VIEW ALL 

Sarah Stahmer, MD

Disclosures

Peer reviewers VIEW ALL 

Amal Mattu, MD

Disclosures

Vias Markides, MB(Hons), BS(Hons), MD, FRCP

Disclosures

Differentials

Guidelines

Patient leaflets

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