What is the initial workup and management for a patient presenting with tachycardia (rapid heart rate)?

From the Guidelines

The initial workup for a patient with tachycardia involves first assessing hemodynamic stability while simultaneously obtaining a 12-lead ECG to determine the type of tachycardia, as recommended by the 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1.

Initial Assessment

The evaluation and management of tachyarrhythmias should focus on signs of increased work of breathing and oxyhemoglobin saturation, with supplementary oxygen provided if necessary, and a monitor attached to the patient to evaluate blood pressure and establish IV access 1.

• Vital signs, including blood pressure, oxygen saturation, and respiratory rate, should be measured immediately.
• A focused history targeting cardiac symptoms, medication use (especially stimulants), and substance abuse is essential, followed by a targeted physical examination.

Management

Management depends on hemodynamic stability and the specific type of tachycardia.

• For unstable patients with signs of shock, altered mental status, or chest pain, immediate synchronized cardioversion at 100-200 joules is indicated 1.
• For stable patients with supraventricular tachycardia, vagal maneuvers should be attempted first, followed by adenosine (6 mg IV rapid push, followed by 12 mg if needed) 1.
• Beta-blockers like metoprolol (5 mg IV) or calcium channel blockers like diltiazem (0.25 mg/kg IV) can be used for rate control in atrial fibrillation or flutter.
• For ventricular tachycardia, amiodarone (150 mg IV over 10 minutes, followed by infusion) is the first-line medication, as recommended by the 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1.

Underlying Causes

Underlying causes such as electrolyte abnormalities, hypoxia, or thyroid disorders must be addressed simultaneously.

• Laboratory tests should include complete blood count, basic metabolic panel, cardiac enzymes, and thyroid function tests.
• Continuous cardiac monitoring is essential throughout evaluation and treatment to track response to interventions and detect any deterioration in rhythm or hemodynamic status.

From the Research

Initial Workup for Tachycardia

• The initial workup for a patient presenting with tachycardia involves determining whether the tachyarrhythmia has a ventricular or supraventricular origin, which drives immediate patient care decisions and long-term management strategies 2.
• A comprehensive history and physical examination, electrocardiography, and laboratory workup are essential components of the diagnostic evaluation 3.
• Extended cardiac monitoring with a Holter monitor or event recorder may be needed to confirm the diagnosis of supraventricular tachycardia (SVT) 3.

Management of Ventricular Tachycardia

• Emergency treatment of ventricular tachycardia (VT) follows the Advanced Cardiac Life Support (ACLS) algorithms for pulseless VT and stable and unstable VT with a pulse 4.
• Catheter ablation and antiarrhythmic drugs (AADs) can reduce implantable cardioverter-defibrillator (ICD) shocks in patients with ischemic cardiomyopathy and symptomatic VT 5.
• In patients with ischemic cardiomyopathy and symptomatic VT, catheter ablation reduced the composite endpoint of cardiovascular death, appropriate ICD shock, hospitalization due to heart failure, or severe treatment-related complications compared to AAD 5.

Management of Supraventricular Tachycardia

• Acute management of paroxysmal SVT is similar across the various types and is best completed in the emergency department or hospital setting 3.
• In patients who are hemodynamically unstable, synchronized cardioversion is first-line management, while vagal maneuvers are first-line management in those who are hemodynamically stable 3.
• Beta blockers and/or calcium channel blockers may be used acutely or for long-term suppressive therapy, and catheter ablation has a high success rate and is recommended as the first-line method for long-term management of recurrent, symptomatic paroxysmal SVT 3.

Differentiation of Wide Complex Tachycardia

• The primary goal of the initial ECG evaluation of every wide complex tachycardia is to determine whether the tachyarrhythmia has a ventricular or supraventricular origin 2.
• Traditional and contemporary methods, including manually applied and automated approaches, can be used to differentiate ventricular tachycardia and supraventricular wide complex tachycardia 2.