Fast Arrhythmias (Tachyarrhythmia)

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The normal heartbeat originates from the heart's normal pacemaker, called the sinus node. A fast arrhythmia occurs when the electrical activity of the heart originates from a location other than this normal pacemaker or when the normal pacemaker activates the heart at an abnormally rapid rate.

Abnormal locations of rhythm origin can be in the upper or lower chambers of the heart, or it can be a "circuit" composed of parts of the upper chambers, the lower chambers, or both.

The normal heart rate varies with age and activity. Babies have a faster heart rate than adults. For each age group, normal ranges have been established. If the heart rate exceeds this limit, a fast rhythm (tachycardia) exists.

What are the basic mechanisms of fast rhythms?

There are two basic mechanisms for fast rhythms: automatic and re-entry. An automatic mechanism occurs when an area of heart tissue generates electrical activity at a rate faster than normal.

Re-entry occurs with the formation of a “circuit” that generates electrical impulses travelling in a circular way, faster than the normal pacemaker. This circuit may involve tissue of the upper chambers, the lower chambers, or both.

Besides the mechanism of the rhythm, arrhythmias are divided based on location of their origin. Fast arrhythmias that originate from the lower chambers (i.e., the ventricles) are called ventricular tachycardias. Those that originate from the upper chambers (i.e., the atria) are termed atrial tachycardias). Fast arrhythmias that do not exclusively originate from the ventricles are termed supraventricular tachycardia (SVT).

Supraventricular tachycardias are usually not dangerous. If they occur very frequently or for prolonged periods of time (hours to days), then they can cause difficulty with the pumping action of the heart. They are not associated in any way with a "heart attack" and only rarely cause sudden death.

Ventricular tachycardia, however, can be more serious and may lead to serious symptoms such as passing out, lightheadedness, or dizziness and possibly cardiac arrest.

In older children and adolescents, the fast heart rate is often felt as palpitations. They recognize that a fast heart rate is occurring at an inappropriate time such as while at rest doing homework or eating dinner. Fast arrhythmias may also cause children or adolescents to pass out (syncope).

Younger children may have difficulty describing this sensation and may complain of chest pain.

In infants, fast arrhythmias are more difficult to detect as they will not complain of symptoms. Some infants may develop poor feeding, irritability, or pallor (unnatural paleness) associated with prolonged fast arrhythmia.

There are many medications available for treatment of fast arrhythmias. The choice of medication depends on the mechanism of the fast rhythm and the patient’s response. Medication does not cure the problem, but can prevent episodes while it is being taken.  In selected cases, a catheterization procedure can be performed to cure the arrhythmia.

  • Atrial tachycardia. A location or an area of the upper chambers takes over the pacemaker activity of the heart. 
  • Atrial flutter / atrial fibrillation. When a large area of the upper chamber is involved in a circuit pattern, atrial flutter can develop. This rhythm can be seen in children who have had previous heart surgery involving the upper chambers.  Children with atrial flutter and fibrillation are at risk for developing clots in the upper chambers because the flow in these chambers is slow.
  • Atrio-ventricular re-entrant tachycardia (AVRT). An extra electrical connection (called "accessory pathway") between the upper and lower chamber allows the formation of a circuit that conducts electrical activity faster than the normal pacemaker. This is the most common form of fast arrhythmias in infancy.

    Many infants with atrio-ventricular re-entrant tachycardia "outgrow" the tachycardia during the first year of life as the accessory pathway becomes unable to function. The specific diagnoses falling in this category include Wolff-Parkinson-White syndrome (WPW) and permanent junctional reciprocating tachycardia (PJRT).
  • Atrio-ventricular nodal re-entrant tachycardia (AVNRT). The atrio-ventricular node (A-V node) is located between the upper and lower chambers of the heart. It is the only area that normally allows the electrical activity of the heart to pass from the upper chambers to the lower chambers.

    Sometimes the region of the A-V node can become a source for a tachycardia. This is the most common form of fast arrhythmias in adolescence.
  • Junctional tachycardia. The origin of the tachycardia is the "junction" between the upper and lower chambers. This is an automatic tachycardia. This tachycardia is seen in patients who have had recent surgery involving this area, for example repair of a ventricular septal defect (VSD), atrioventricular septal defect or tetralogy of Fallot.

Ventricular Tachycardia

When the source of the fast heart rate is the lower chambers (ventricles), ventricular tachycardia (VT) is present.

Ventricular tachycardia is relatively uncommon in children. It can be seen in patients with congenital heart disease, especially those who, despite surgery, continue to have problems with heart function.

Ventricular tachycardia is also seen with other conditions. Among the most common are prolonged QT syndrome, hypertrophic cardiomyopathy and myocarditis.

Recording the heart rhythm while the patient is having an episode confirms the diagnosis. This can be done in an emergency room or a physician's office capable of performing electrocardiograms.

In some cases, an "event monitor" is given to the patient to record the heart's electrical activity at home. When the symptom occurs, the monitor is used to record the heart rhythm. The recording can then be transmitted by telephone for review by the cardiologist.  Implanted monitors can be used to record rhythms that are brief and infrequent.

After Diagnosis

The first objective needs to be consultation with your cardiologists regarding the risks of the fast rhythm and the risks and benefits of its treatment. If the fast rhythm has a "benign" course with little impact on daily life, observation may be warranted.

On the other hand, an infrequent fast rhythm that is a cause for concern to either the patient, family, or physician may require therapy. If the fast rhythm recurs despite therapy, the symptoms usually would be the same as before therapy.

The most important thing to learn is taking your child's pulse and knowing the "normal" rate for her / his age. With guidance from your physician, this is an easily acquired skill. The ability to count your child's heart rate can be reassuring to you and helpful to your doctor when making a diagnosis.

Last Updated 06/2014