The MKSAP Challenge
Answer: C
Educational Objective: Recognize the clinical presentation of paroxysmal supraventricular tachycardia.
The abrupt onset and regularity of the palpitations strongly suggest paroxysmal reentrant supraventricular arrhythmia. Resolution of the episodes may appear gradual because the arrhythmia may convert to sinus tachycardia that gradually slows.
The most common type of paroxysmal reentrant supraventricular arrhythmia is atrioventricular nodal reentrant tachycardia, which involves reentry within atrioventricular nodal tissue. Her awareness of the palpitations as a pounding sensation in the neck is a common finding in supraventricular tachycardia. It likely is related to nearly simultaneous contractions of the atria and ventricles during supraventricular tachycardia, when the ventricularnatrial ratio is 1:1.
Palpitations associated with premature ventricular contractions feel like skipped beats or an irregular pulse. Although palpitations are sometimes associated with mitral valve prolapse, this patient has no findings that suggest this. Paroxysmal supraventricular tachycardia is much more common in this age group than is ventricular tachycardia, and atrial flutter is rare in a young, healthy person who has a normal heart. In a young person who has exercise-induced palpitations, a catecholamine-sensitive tachycardia, such as right ventricular outflow tract ventricular tachycardia, must be considered.
References:
1. Zipes DP, DiMarco JP, Gillette PC, Jackman WM, Myerburg RJ, Rahimtoola SH, et al. Guidelines for clinical intracardiac electrophysiological and catheter ablation procedures. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Clinical Intracardiac Electrophysiologic and Catheter Ablation Procedures), developed in collaboration with the North American Society of Pacing and Electrophysiology. J Am Coll Cardiol. 1995;26:555-73.
2. Brugada P, Gursoy S, Brugada J, Andries E. Investigation of palpitations. The Lancet. 1993;341:1254-8.
3. Basta M, Klein GJ, Yee R, Krahn A, Lee J. Current role of pharmacologic therapy for patients with paroxysmal supraventricular tachycardia. Cardiol Clin. 1997;15:587-97.
4. Gold MR, Josephson ME. Cardiac arrhythmia: current therapy. Hosp Pract (Off Ed). 1999;34:27-8, 31-2, 35-8 passim.
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