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Updated: Aug 19 2022

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
    • Associated conditions
      • COPD
  • 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
  • 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
  • Prognosis
    • Mortality is high but often due to multiple medical comorbidities in these patients rather than from MAT itself
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