Salbutamol-Induced Narrow QRS Tachycardia: What Is: The Mechanism?

792
ARRHYTHMIA ROUNDS
Editor: George J. Klein, M.D.
Salbutamol-Induced Narrow QRS Tachycardia: What Is

the Mechanism?
MARIA PIA CALABRÒ, M.D.,∗ FRANCESCO L. DE LUCA, M.D.,∗ ELOISA GITTO, M.D.,∗
and GIUSEPPE ORETO, M.D.†
From the Departments of ∗ Pediatrics and †Cardiology, University Hospital, Messina, Italy
Case Presentation less likely diagnosis is atrioventricular re-entrant tachycardia

due to a left-sided accessory pathway with a long conduction
The electrocardiogram of Figure 1 shows a narrow QRS time.1,2
tachycardia, recorded from a 3-year-old female patient with- The ventricular complexes are abnormal, because leads I,
out history of heart disease, admitted following accidental II, and aVL show a qR configuration with deep q waves (a
ingestion of 24 mg of salbutamol (a dose more than 6 times trivial initial positive deflection, however, appears in lead I);
higher than the maximal one recommended at this age). in addition, all the chest leads reflect deep and narrow Q waves
Tachycardia rate is 195 per minute. The QRS complexes are followed by relatively tall R waves, an S wave being present
narrow, and each of them is preceded by a P wave that is only in leads V4R and V1. The parents of the child revealed
negative in leads I and aVL and positive in the inferior leads that the patient was affected by congenital right lung agenesia;
and in lead V1. What is the mechanism of tachycardia? the chest X-ray showed that the heart was totally displaced
to the right chest due to absence of the right lung (Fig. 2). It
Commentary was, therefore, hypothesized that both the abnormal P wave
axis and the unexpected QRS morphology were due to the
At first glance, the most likely diagnosis is ectopic atrial
marked cardiac displacement within the chest.
tachycardia arising from the left atrium, on the basis of: (1)
The P vector shift to the right, with negative P wave in lead
narrow QRS complexes preceded by P waves with a constant
I, is somewhat surprising in dextroversion due to right lung
P-R interval of 120 msec; (2) P wave axis at about +150◦ . A
agenesia: such a pattern has been emphasized as the most
constant and valuable sign of mirror-image dextrocardia,3,4
J Cardiovasc Electrophysiol, Vol. 17, pp. 792-793, July 2006. whereas positive P waves in lead I have been considered as
Address for correspondence: Giuseppe Oreto, Via Terranova, 9, 98122
Messina, Italy. Fax: +39 090 2213845; E-mail oretogmp@tin.it
doi: 10.1111/j.1540-8167.2006.00481.x
Figure 1. Electrocardiogram recorded on admission. Figure 2. Chest X-ray of the patient.

Calabrò et al. Salbutamol-Induced Narrow QRS Tachycardia 793
Figure 3. Electrocardiogram recorded after

tachycardia termination.
typical of dextroversion.5 In some cases of dextroversion, tricle and mainly record a ventricular complex with qR con-
however, a negative P wave was present in lead I6,7 ; in partic- figuration; in addition, the R waves in the left chest leads
ular, one patient with ventricular septal defect and dextrover- are of minor amplitude than those in the right leads, being
sion due to right lung agenesia, in which the heart malposition the recording electrodes of V4 or V6 relatively far from the
was assessed during open heart surgery, showed a rightward heart.
P axis, with negative P wave in lead I.6
Salbutamol, a β-receptor agonist, commonly results in si- References
nus tachycardia, so that a diagnosis of sinus tachycardia was 1. Calabrò MP, Luzza F, Carerj S, Oreto G: Narrow QRS tachycardia with
entertained on the basis of the high amount of drug ingested, negative P waves in leads I and aVL: What is the mechanism? J Cardio-
and propranolol was administered. This resulted in progres- vasc Electrophysiol 2003;14:1013-1014.
sive reduction of the heart rate up to about 100 per minute, 2. Gaita G, Haissaguerre M, Giustetto C, Fischer B, Riccardi R, Richiardi
E, Scaglione M, Lamberti F, Warin JF: Catheter ablation of permanent
with unchanged P wave and QRS complex configuration junctional reciprocating tachycardia with radiofrequency current. J Am
(Fig. 3). Subsequent electrocardiograms, performed during Coll Cardiol 1995;25:648-654.
a 6-month follow-up, always showed the same P wave axis 3. Arcilla RA, Gasul BM: Congenital dextrocardia. Clinical, angiocardio-
and configuration as during tachycardia. Although it is the- graphic, and autopsy studies on 50 patients. J Pediatr 1961;58:251-262.
4. Espino Vela J, Martinez CG, Ginefra P, Portillo B, Echeverria VM, Pi-
oretically possible that the patient had a persistent left atrial leggi F, Correa R: Contribucion al estudio de la dextrocardias. Analisis
rhythm both at rest and during salbutamol-induced tachycar- de 36 casos. Arch Inst Cardiol México 1960;30:117-150.
dia, it is more likely that sinus rhythm resulted in abnormal P 5. Burchell HB, Pugh DG: Uncomplicated isolated dextrocardia (“dextro-
wave axis and configuration due to the extremely abnormal versio cordis” type). Am Heart J 1952;44:196-206.
heart position; when sinus tachycardia occurred, the pattern 6. Mirowski M, Neill CA, Bahnson HT, Taussig HB: Negative P waves
in dextroversion: Differential diagnosis from mirror-image dextrocardia.
mimicked an ectopic tachycardia arising from the left atrium. Circulation 1962;26:413-420.
The dextroposition of the heart also explains the uncom- 7. Balducci G, Caruso G, Di Lecce A, Ricco R: Insolito quadro elettro-
mon QRS complex configuration, namely the presence of cardiografico da destroposizione anatomica. G Ital Cardiol 1981;11:692-
qR complexes in almost all the precordial leads as well as 697.
8. Schamroth L: The 12 lead Electrocardiogram. Oxford: Blackwell Scien-
the deep q waves in the limb leads.6,8,9 This unexpected tific Publications, 1989:343-344.
pattern is due to the fact that, as a consequence of heart 9. Schamroth L, Hurwitz S, Conlan A: A concordant pattern. Heart Lung
displacement, all the leads are oriented toward the left ven- 1981;10:329-330.

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792

Salbutamol-Induced Narrow QRS Tachycardia: What Is

Case Presentation less likely diagnosis is atrioventricular re-entrant tachycardia

Figure 1. Electrocardiogram recorded on admission. Figure 2. Chest X-ray of the patient.

Figure 3. Electrocardiogram recorded after

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