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For further information, see CMDT Part 10-34: Atrial Tachycardia

Key Features

Essentials of Diagnosis

  • Characterized by bursts of rapid, regular tachycardia

  • Multifocal atrial tachycardia commonly seen with severe chronic obstructive pulmonary disease (COPD) and presents with three or more distinct P wave morphologies on ECG, often confused for atrial fibrillation

  • Treatment of the underlying lung disease is most effective therapy

General Considerations

  • Atrial tachycardia

    • An uncommon form of supraventricular tachycardia (SVT)

    • Characterized by paroxysms or bursts of rapid, regular arrhythmia due to focal atrial impulses originating outside of the normal sinus node

    • Common sites include the

      • Tricuspid annulus

      • Crista terminalis of the right atrium

      • Coronary sinus

  • Multifocal atrial tachycardia

    • A particular subtype seen in patients with severe COPD

    • Characterized by

      • Varying P wave morphology (by definition, three or more foci)

      • Markedly irregular PP intervals

    • The rate is usually between 100 beats/min and 140 beats/min

    • Often confused for atrial fibrillation

  • Solitary atrial premature beats

    • Benign and generally not associated with underlying cardiac disease

    • Occur when an ectopic focus in the atria fires before the next sinus node impulse

    • The contour of the P wave usually differs from the patient's normal complex, unless the ectopic focus is near the sinus node

    • Acceleration of the heart rate by any means usually abolishes most premature beats

Clinical Findings

  • Usually intermittent and self-limiting

  • Incessant forms do exist and may present with signs and symptoms of heart failure due to tachycardia-induced cardiomyopathy

  • Palpitations with an abrupt onset, similar to other forms of paroxysmal supraventricular tachycardia (PSVT)

  • Dyspnea or angina can present in patients with underlying cardiac pathology (eg, coronary heart disease [CHD])


  • 12-lead ECG

    • Close inspection of the P wave suggests a focus away from the sinus node, although certain locations (eg, high right atrial crista terminalis) may mimic sinus tachycardia

    • In this situation, the abrupt onset and offset of the arrhythmia is helpful in distinguishing atrial from sinus tachycardia, although electrophysiologic study is sometimes necessary


  • Atrial tachycardia

    • Initial management is similar to other types of PSVT

    • However, vagal maneuvers and intravenous adenosine are generally less effective

    • Intravenous β-blockers or calcium channel blockers can be given in the hemodynamically stable patient with a transition to oral formulations for long-term management

    • Antiarrhythmic medications or catheter ablation should be considered in patients who continue to have symptomatic episodes. Long-term anticoagulation is not indicated in the absence of coexistent atrial fibrillation or atrial flutter

  • Multifocal atrial tachycardia

    • Treatment of the underlying condition (eg, COPD) is paramount

    • Verapamil, 240–480 mg orally daily in divided doses, may be effective


When to Refer

  • All patients with atrial tachycardia in whom initial medical management fails should be referred to ...

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