Initial Onset of Accessory Pathway‐Mediated and Atrioventricular Node Reentrant Tachycardia After Age 65: Clinical Features, Electrophysiologic Characteristics, and Possible Facilitating Factors
Authors: Chen Shih‐Ann , Lee Shih‐Huang , Wu Tsu‐Juey , Chiang Chern‐En , Cheng Chen‐Chuen , Tai Ching‐Tai , Chiou Chuen‐Wang , Ueng Kwo‐Chang , Wen Zu‐Chi , Chang Mau‐Song 
Published: April 2015

OBJECTIVE:To evaluate the clinical features electrophysiologic characteristics, and possible facilitating factors in older patients (≤ 65 years) with initial onset of accessory pathway‐mediated and atrioventricular (AV) node reentrant tachycardia.

DESIGN:Of the patients undergoing electrophysiologic study and radiofrequency catheter ablation of accessory pathway‐mediated and AV node reentrant tachycardia at this institution, patients with initial tachyarrhythmia after age 65 years were compared with those presenting initially before age 30.

SETTING:A tertiary medical center for the general public.

PARTICIPANTS:Sixty‐six patients had their initial symptoms after age 65: Group I, 32 patients with accessory pathway‐mediated tachycardia, and Group II, 34 patients with AV node reentrant tachycardia. Four‐hundred forty patients had their initial symptoms before age 30: Group III, 283 with accessory pathway mediated tachyarrhythmia, and Group IV, 157 with AV node reentrant tachycardia.

INTERVENTION:All patients underwent electrophysiological study to determine the mechanisms of tachyarrhythmia, and radiofrequency catheter ablation for treatment of tachycardia.

RESULTS:(1) Older patients with initial arrhythmia had incidence of critical clinical manifestations, including tachyarrhythmia‐related syncope and cardioversion, similar to those with initial arrhythmia at a younger age. (2) Patients in Group III, showed anterograde effective refractory period (ERP) of the AV node (P = .432), longer anterograde ERP of the accessory pathway (P = .004), and greater difference of the anterograde ERP between the AV node and the accessory pathway (D‐ERP) (P = .003) similar to patients in group I. In Group II, the ERP and Wenckebach cycle length of the retrograde fast pathway was significantly longer than in Group IV (P = .037 and P < .001, respectively), and a greater percentage of patients in Group II than in Group IV AV node reentrant tachycardia needed isoproteronol to facilitate the induction of reentrant tachycardia (P = .034). (3) Patients in Group I and Group II had a higher incidence of supraventricular and ventricular ectopic activity than those in Group III (P = .002 and P = .005, respectively) and Group IV (P = .024 and P = .012, respectively) in 24‐hour ambulatory electrocardiograms.

CONCLUSION:The initial onset of accessory pathway‐mediated tachycardia after age 65 may be caused by changes of electrophysiologic properties (greater D‐ERP) as well as increased supraventricular and ventricular ectopic activity. Influence of the autonomic nervous system, rather than changes of conduction properties in the AV node, and increase in ectopic activity may contribute to the new onset of AV node reentrant tachycardia in older adults. The choice of antiarrhythmic drugs and radiofrequency ablation require attention to the clinical profile and facilitating factors of reentrant tachycardia in this group of patients.