Sinus node reentrty tachycardia vs atrial reentry tachycardia


An adult pt is admitted due to SOB and managed as CHF. Echo showed EF in the 30's.



The basic rhythm is sinus (initial rate ~80's-100s) then there is abrupt decrease of rate (~ 50's bpm) with a slightly different P wave morphology (but still a normal PRI).

The differential diagnoses are: 

1. Inappropriate sinus tachycardia (IST)
2. Atrial reentry tachycardia (ART)near the sinus node
3. Sinoatrial reentry tachycardia (SART/SNRT)

IST is non-paroxysmal, elevated resting rate and gradual (excessive acceleration as reaction to mild exercise.However, as we  see in the strip, this is paroxysmal. Thus, IST is ruled-out.

ART - paroxysmal and difficult to differentiate from SART.

Sinus node reentry is defined as a reentrant tachycardia involving the sinus node and perinodal tissue.  It is possible that SNRT may represent a high cristal atrial tachycrdia (AT) originating near the sinus node . The features of SART/SNRT are:

The features of SART/SNRT are:

1. Abrupt onset/termination (may have gradual slowing)
2. Similar p-wave morphology compared to regular sinus beats (or may differ slightly)/ upright in leads II, III and aVF
3. Rate may vary from 80-140 bpm (ave apprx 100-110)

Thus, this is ART vs SART/SNRT.

References:

Das and Zipes. 2012. Electrocardiography of arrhythmias : a comprehensive review. Elsevier PA

Fisch C and Knoebel SB. 2000. Electrocardiography of Clinical Arrhytmias. Futura Pub NY

Mohammad-Reza et al.1985 Sinus Node Reentry: Case Report and Review of Electrocardiographic and Electrophysiologic Features. Texas Heart Institute 12(3) 249-252 - http://www.ncbi.nlm.nih.gov/.../pdf/thij00003-0044.pdf

Sanders et al. 1994. Catheter Ablation of Sinus Node Reentry Tachycardia. JACC 23 (4) 926-934

Simmers TA and Seeram N. 2003. Sinoatrial Reentry Teacycardia: A Review. Indian Pacing and Electrophsiology 3(3):109-116 - http://www.ncbi.nlm.nih.gov/.../PMC.../pdf/ipej030109-00.pdf

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