© 2003 by European Society of Cardiology
Distinction between atrioventricular reciprocating tachycardia and atrioventricular node re-entrant tachycardia in the adult population based on P wave location
Should we reconsider the value of some ECG criteria according to gender and age?
1Cardiovascular Department Hôpital de la Tour, Meyrin, Switzerland; 2Division of Cardiology, Centre Hospitalier Universitaire Vaudois Lausanne, Switzerland
AIMS: Distinction between atrioventricular node re-entrant tachycardia (AVNRT) and atrioventricular reciprocating tachycardia (AVRT) is sometimes difficult using location of retrograde P waves on ECG.
METHODS: P wave location was retrospectively determined in 137 anterior slow-fast AVNRT (85%) and 26 orthodromic AVRT (15%) with narrow QRS occurring in 161 successive patients without pre-excitation. Mechanism of arrhythmia was assessed by electrophysiological study and confirmed by the efficacy of radiofrequency ablation. P waves were classified as invisible, visible after the QRS, or as R' in V1 and/or S in II. Correlations with arrhythmia mechanism were made according to gender and age (> or 
65 years old).
RESULTS: Mechanism was related to gender but not to age, with a higher proportion of AVNRT in women (89/97, 91%) than in men (48/66, 72%) (P=0.001). AVRT presented with visible P waves in 26/26 cases (100%) while AVNRT presented with invisible P waves in 36/137 (27%), R'V1/SII in 79/137 (57%) and visible P waves in 22/137 (16%). P wave location during AVNRT was related to age but not to gender, with a higher proportion of AVNRT with visible P waves in elderly than in younger patients: 8/27 (29%) vs 14/110 (12%) (P=0.03). Visible P wave during AVNRT was mainly caused by a delay in nodal retrograde conduction in 17/22 patients (77%). Mechanism of tachycardia with visible P waves was related to gender (AVNRT in 14/22 women (64%), AVRT in 18/26 men (70%),P =0.02) and to age, although non-significantly (AVNRT in 8/13 (62%) old vs 14/35 (40%) young patients, P=0.18). A visible P wave was predictive of AVNRT in 25% and in 60% of the men and women younger than 65 years old, and in 50% and in 71% of older men and women respectively (P=0.08 — borderline significance).
CONCLUSIONS: Correct distinction between anterior slow-fast AVNRT and orthodromic AVRT can be reliably made regardless of gender or age in case of R'V1/SII or invisible P wave. AVRT as the expected mechanism should be reconsidered in the case of visible P waves in the elderly and in the female gender in the absence of pre-excitation.
Key Words: Atrioventricular node re-entrant tachycardia, atrioventricular reciprocating tachycardia, retrograde atrio-ventricular conduction, retrograde P wave, gender, age
Correspondence: P. Maury, Cardiologie, Hopital de Rangueil, 1 avenue Jean Poulhès, Toulouse, France. Tel.: (33) 561322094; Fax: (33) 561322246.
[1] Farre J and Wellens HJJ. Value of the electrocardiogram in diagnosing site of origin and mechanism of supraventricular tachycardia. In Wellens HJJ and Kulbertus HE (Eds.). What's New in Electrocardiography 1981; The Hague Martinus Nijhoff pp. 131–171.
[2] Akhtar M, Jazayeri MR, Sra J, Blanck S, Deshpande S, Dhala A. Atrioventricular nodal reentry. Clinical, electrophysiological and therapeutic considerations. Circulation 1993; 88: 282–295.
[3] Kalbfleisch SJ, El-Atassi R, Calkins H, Langberg JJ, Morady F. Differentiation of paroxysmal narrow complex tachycardias using the 12-lead electrocardiogram. J Am Coll Cardiol 1993; 21: 85–89.[Abstract]
[4] Csanadi Z, Klein GJ, Yee R, Thakur RK, Li H. Effect of dual atrioventricular node pathways on atrioventricular reentrant tachycardia. Circulation 1995; 91: 2614–2618.
[5] Wu D, Denes P, Amat-Y-Leon F, et al. Clinical, electrocardiographic and electrophysiologic observations in patients with paroxysmal supraventricular tachycardia. Am J Cardiol 1978; 41: 1045–1051.[CrossRef][Web of Science][Medline]
[6] Chen SA, Chiang CE, Yang CJ. Accessory pathway and atrioventricular node reentrant tachycardia in elderly patients: clinical features, electrophysiologic characteristics and results of radiofrequency ablation. J Am Coll Cardiol 1994; 23: 702–708.[Abstract]
[7] Kadish AH. The effects of gender on cardiac electrophysiology and arrhythmias. In Zipes DP and Jalife J (Eds.). Cardiac Electrophysiology. From Cell to Bedside 1995; 2nd edn Philadelphia Saunders pp. 1268–1275.
[8] Jazayeri MR, Sra JS, Deshpande SS, et al. Electrophysiologic spectrum of atrioventricular nodal behavior in patients with atrioventricular nodal reentrant tachycardia undergoing selective fast or slow pathway ablation. J Cardiovasc Electrophysiol 1993; 4: 99–111.[Web of Science][Medline]
[9] Sung RJ, Lauer MR, Chun H. Atrioventricular node reentry: current concepts and new perspectives. Pacing Clin Electrophysiol 1994; 17: 1413–1430.[CrossRef][Medline]
[10] McGuire MA, Janse MJ, Ross DL. ‘AV nodal’ reentry part II: AV nodal, AV junctional, or Atrionodal reentry? J Cardiovasc Electrophysiol 1993; 4: 573–586.[Web of Science][Medline]
[11] McGuire MA, Lau KC, Johnson DC, Richards DA, Uther JB, Ross DL. Patients with two types of atrioventricular junctional (AV nodal) reentrant tachycardia. Evidence that a common pathway of nodal tissue is not present above the reentrant circuit. Circulation 1991; 83: 1232–1246.
[12] Kieny JR, Kirkorian G, Atallah G, Touboul P. Diagnostic du mécanisme des tachycardies réciproques par une exploration électrophysiologique simplifiée. Arch Mal Coeur 1991; 84: 763–770.
[13] Calkins H, Sousa J, El-Atassi RE. Diagnosis and cure of the Wolff-Parkinson-White syndrome or paroxysmal supraventricular tachycardias during a single electrophysiologic test. N Engl J Med 1991; 324: 1612–1618.[Abstract]
[14] McGuire MA, Yip ASB, Lau KC. Posterior (‘atypical’) atrioventricular junctional reentrant tachycardia. Am J Cardiol 1994; 73: 469–477.[CrossRef][Web of Science][Medline]
[15] Tai CT, Chen SA, Chiang CE. A new electrocardiographic algorithm using retrograde P waves for differentiating atrioventricular node reentrant tachycardia from atrioventricular reciprocating tachycardia mediated by concealed accessory pathway. J Am Coll Cardiol 1997; 29: 394–402.[Abstract]
[16] Bär FS, Brugada P, Dassen WRM, Wellens HJJ. Differential diagnosis of tachycardia with narrow QRS complex (shorter than 0.12 second). Am J Cardiol 1984; 54: 555–560.[CrossRef][Web of Science][Medline]
[17] Munger TM, Packer DL, Hammill SC. A population study of the natural history of Wolff-ParkinsonWhite syndrome in Olmsted County, Minnesota, 1953–1989. Circulation 1993; 87: 866–873.
[18] Ross DL and Uther JB. Diagnosis of concealed accessory pathways in supraventricular tachycardia. Pacing Clin Electrophysiol 1984; 7: 1069–1085.[Medline]
[19] Rodriguez LM, De Chillou C, Schläpfer J, et al. Age at onset and gender of patients with different types of supraventricular tachycardias. Am J Cardiol 1992; 70: 1213–1215.[CrossRef][Web of Science][Medline]
[20] Wellens HJJ and Dürrer D. The role of an atrioventricular accessory pathway in reciprocal tachycardia. Observations in patients with and without the Wolff-Parkinson-White syndrome. Circulation 1975; 52: 58–72.
[21] Coumel P, Attuel P, Motté G, Slama R, Bouvrain Y. Les tachycardies jonctionnelles paroxystiques: évaluation du point de jonction inférieur. Démembrement des ‘rythmes réciproques intra-nodaux’. Arch Mal Coeur 1975; 68: 1255–1268.
[22] Kay GN, Epstein AE, Dailey SM, Plumb VJ. Role of radiofrequency ablation in the management of supraventricular arrhythmias: experience in 760 consecutive patients. J Cardiovasc Electrophysiol 1993; 4: 371–389.[Web of Science][Medline]
[23] Guize L, Soria R, Chaouat JC, Chrétien JM, Houé D, Le Heuzey JY. Prevalence et evolution du syndrome de Wolff-Parkinson-White dans une population de 138048 sujets. Ann Med Int 1985; 136: 474–478.[Medline]
[24] Kounis NG, Zavras GM, Papadaki PJ, Soufras GD, Kitrou MP, Poulos EA. Pregnancy-induced increase of supraventricular arrhythmias in Wolff-Parkinson-White Syndrome. Clin Cardiol 1995; 18: 137–140.[Medline]
[25] Kay GN, Pressley JC, Packer DL, Pritchett ELC, German LD, Gilbert MR. Value of the 12-lead electrocardiogram in discriminating atrioventricular nodal reciprocating tachycardia from circus movement atrioventricular tachycardia utilizing a retrograde accessory pathway. Am J Cardiol 1987; 59: 296–300.[CrossRef][Web of Science][Medline]
[26] Akhtar M, Damato AN, Ruskin JN, et al. Antegrade and retrograde conduction characteristics in three patterns of paroxysmal atrioventricular junctional reentrant tachycardia. Am Heart J 1978; 95: 22–42.[CrossRef][Web of Science][Medline]
[27] Leier CV, Meacham JA, Schaal SF. Prolonged atrial conduction. A major predisposing factor for the development of atrial flutter. Circulation 1978; 57: 213–216.
[28] Josephson ME, Scharf DL, Kastor JA, Kitchen GJ III. Atrial endocardial activation in man. Electrode catheter technique for endocardial mapping. Am J Cardiol 1977; 39: 972–981.[Medline]
[29] Rosenfeld LE, Van Zetta AM, Batsford WP. Comparison of clinical and electrophysiologic features of preexcitation syndromes in patients presenting initially after age 50 years with those presenting at younger age. Am J Cardiol 1991; 67: 709–712.[Medline]
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