Updated: 2/2/2020

Multifocal Atrial Tachycardia

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Snapshot
  • A 72-year-old man is admitted to the medicine floor for a chronic obstructive pulmonary disease exacerbation. On the second day, he reports feeling lightheaded and having some chest pain. His telemetry at that time reveals an irregular rhythm with a pulse of 120/min. Electrocardiogram reveals an irregularly irregular rhythm, tachycardia, discrete P waves before every QRS complex, and at least 3 different P wave morphologies.
Introduction
  • Clinical definition
    • an atrial arrhythmia characterized by irregular and rapid rhythm
      • associated with pulmonary pathologies
  • Epidemiology
    • risk factors
      • chronic lung disease
  • Etiology 
    • decompensated chronic lung disease
      • chronic obstructive pulmonary disease (COPD) is the most common underlying illness
    • heart failure
    • structural heart damage
    • methylxanthine toxicity
  • Pathogenesis
    • multiple sites of competing atrial activity causes irregular atrial tachycardia with multiple P wave morphologies
  • Associated conditions
    • COPD
  • Prognosis
    • mortality is high but often due to multiple medical comorbidities in these patients rather than from MAT itself
Presentation
  • Symptoms
    • may be asymptomatic
    • symptoms may be precipitated by exacerbation of underlying disease, such as COPD 
      • palpitations
      • shortness of breath
      • lightheadedness
      • syncope
      • chest pain
  • Physical exam
    • often hypoxic at baseline
    • rapid and irregular pulse
Studies
  • Electrocardiogram 
    • irregularly irregular rhythm with > 100 beats per minute
    • polymorphic P waves
      • at least 3 different P wave forms
    • discrete P waves before each QRS complex
    • PR interval varies from beat to beat
  • Making the diagnosis
    • based on clinical presentation and electrocardiogram 
Differential
  • Atrial fibrillation 
    • distinguishing factor
      • electrocardiogram with atrial fibrillation (irregularly irregular heartbeat with no discrete P waves before each QRS complex) rather than MAT
  • Atrial flutter 
    • distinguishing factor
      • electrocardiogram shows rapid regular rhythm and “sawtooth” appearance of the waves
  • Premature atrial contractions
    • palpitations and ectopic P-waves with a beat earlier than expected 
Treatment
  • Management approach
    • avoid β-blockers
      • patients typically have underlying lung disease
      • β-blockers can cause bronchospasms
    • oxygen is usually given first followed by medication
  • Medical
    • non-dihydropyridine calcium channel blockers
      • indication
        • for all patients
      • mechanism of action
        • this class of calcium channel blockers directly act on the heart
        • decreases atrial activity
        • slows atrioventricular node conduction
      • drugs 
        • diltiazem
        • verapamil
Complications
  • Emboli
  • Myocardial infarction

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(M3.CV.15.13) An 86-year-old man with a history of COPD, hypertension, and diabetes presents to the emergency department with dyspnea and palpitations. He states his symptoms started 1 hour ago and have persisted. His temperature is 100.0°F (37.8°C), blood pressure is 157/98 mm Hg, pulse is 130/min, respirations are 23/min, and oxygen saturation is 90% on room air. Physical exam is notable for digital clubbing, bilateral wheezing, and an obese abdomen. An ECG is performed as seen in Figure A. The patient is given continuous albuterol-ipratropium nebulizers with minimal improvement. Which of the following is the best next step in management?

QID: 102954
FIGURES:
1

Amiodarone

20%

(1/5)

2

Aspirin

0%

(0/5)

3

Digoxin

0%

(0/5)

4

Diltiazem

60%

(3/5)

5

Metoprolol

20%

(1/5)

M 11 E

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Evidence (4)
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