792
ARRHYTHMIA ROUNDS
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
The electrocardiogram of Figure 1 shows a narrow QRS
tachycardia, recorded from a 3-year-old female patient with-
out history of heart disease, admitted following accidental
ingestion of 24 mg of salbutamol (a dose more than 6 times
higher than the maximal one recommended at this age).
Tachycardia rate is 195 per minute. The QRS complexes are
narrow, and each of them is preceded by a P wave that is
negative in leads I and aVL and positive in the inferior leads
and in lead V1. What is the mechanism of tachycardia?
Commentary
At first glance, the most likely diagnosis is ectopic atrial
tachycardia arising from the left atrium, on the basis of: (1)
narrow QRS complexes preceded by P waves with a constant
P-R interval of 120 msec; (2) P wave axis at about +150◦ . A
J Cardiovasc Electrophysiol, Vol. 17, pp. 792-793, July 2006.
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.
Editor: George J. Klein, M.D.
less likely diagnosis is atrioventricular re-entrant tachycardia
due to a left-sided accessory pathway with a long conduction
time.1,2
The ventricular complexes are abnormal, because leads I,
II, and aVL show a qR configuration with deep q waves (a
trivial initial positive deflection, however, appears in lead I);
in addition, all the chest leads reflect deep and narrow Q waves
followed by relatively tall R waves, an S wave being present
only in leads V4R and V1. The parents of the child revealed
that the patient was affected by congenital right lung agenesia;
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
was, therefore, hypothesized that both the abnormal P wave
axis and the unexpected QRS morphology were due to the
marked cardiac displacement within the chest.
The P vector shift to the right, with negative P wave in lead
I, is somewhat surprising in dextroversion due to right lung
agenesia: such a pattern has been emphasized as the most
constant and valuable sign of mirror-image dextrocardia,3,4
whereas positive P waves in lead I have been considered as
Figure 2. Chest X-ray of the patient.
 Calabrò et al. Salbutamol-Induced Narrow QRS Tachycardia
Figure 3. Electrocardiogram recorded after
tachycardia termination.
typical of dextroversion.5 In some cases of dextroversion,
however, a negative P wave was present in lead I6,7 ; in partic-
ular, one patient with ventricular septal defect and dextrover-
sion due to right lung agenesia, in which the heart malposition
was assessed during open heart surgery, showed a rightward
P axis, with negative P wave in lead I.6
Salbutamol, a β-receptor agonist, commonly results in si-
nus tachycardia, so that a diagnosis of sinus tachycardia was
entertained on the basis of the high amount of drug ingested,
and propranolol was administered. This resulted in progres-
sive reduction of the heart rate up to about 100 per minute,
with unchanged P wave and QRS complex configuration
(Fig. 3). Subsequent electrocardiograms, performed during
a 6-month follow-up, always showed the same P wave axis
and configuration as during tachycardia. Although it is the-
oretically possible that the patient had a persistent left atrial
rhythm both at rest and during salbutamol-induced tachycar-
dia, it is more likely that sinus rhythm resulted in abnormal P
wave axis and configuration due to the extremely abnormal
heart position; when sinus tachycardia occurred, the pattern
mimicked an ectopic tachycardia arising from the left atrium.
The dextroposition of the heart also explains the uncom-
mon QRS complex configuration, namely the presence of
qR complexes in almost all the precordial leads as well as
the deep q waves in the limb leads.6,8,9 This unexpected
pattern is due to the fact that, as a consequence of heart
displacement, all the leads are oriented toward the left ven-
793
tricle and mainly record a ventricular complex with qR con-
figuration; in addition, the R waves in the left chest leads
are of minor amplitude than those in the right leads, being
the recording electrodes of V4 or V6 relatively far from the
heart.
References
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