AUCTORES
Globalize your Research
Chat with us
Case Report | DOI: https://doi.org/10.31579/2641-0419/315
Supraventricular tachycardias (SVTs) are common arrhythmias in clinical practice – they produce symptoms and lead to frequent emergency department visits1,2. The term “SVT” refers to tachyarrhythmias with a ventricular rate > 100bpm, where the mechanism for the arrythmia involves cardiac tissues above the bundle of His. The majority of SVTs conduct to the ventricles using the His-Purkinje system thereby producing a narrow QRS (< 120bpm). Presence of bundle branch blocks or other methods of aberrancy can result in SVT that presents as a wide QRS tachycardia.
*Corresponding Author: Pavel Antiperovitch
Citation: Pavel Antiperovitch, Allan Skanes, George Klein (2023), A Rational Approach to the Diagnosis of Narrow Complex Tachycardia. J. Clinical Cardiology and Cardiovascular Interventions, 6(5); DOI:10.31579/2641-0419/315
Copyright: © 2023, Pavel Antiperovitch. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 28 March 2023 | Accepted: 25 April 2023 | Published: 05 June 2023
Keywords: supraventricular tachycardias; arrhythmias; qrs tachycardia
Supraventricular tachycardias (SVTs) are common arrhythmias in clinical practice – they produce symptoms and lead to frequent emergency department visits1,2. The term “SVT” refers to tachyarrhythmias with a ventricular rate > 100bpm, where the mechanism for the arrythmia involves cardiac tissues above the bundle of His. The majority of SVTs conduct to the ventricles using the His-Purkinje system thereby producing a narrow QRS (< 120bpm). Presence of bundle branch blocks or other methods of aberrancy can result in SVT that presents as a wide QRS tachycardia.
Supraventricular tachycardias (SVTs) are common arrhythmias in clinical practice – they produce symptoms and lead to frequent emergency department visits [1,2]. The term “SVT” refers to tachyarrhythmias with a ventricular rate > 100bpm, where the mechanism for the arrythmia involves cardiac tissues above the bundle of His. The majority of SVTs conduct to the ventricles using the His-Purkinje system thereby producing a narrow QRS (< 120bpm>
When approaching a problem on a tracing, it is best to create a list of differential diagnoses. A list of common differential diagnoses is included in Figure 1. However, many diagnoses share mechanistic features, and are often grouped together into 4 main categories: atrial tachycardia (AT), AV Nodal Re-entrant Tachycardia (AVNRT), Atrioventricular Re-entrant Tachycardia (AVRT), and Junctional Tachycardia (JT).
Figure 1 - Differential diagnosis of a narrow complex tachycardia. NOTE: Ventricular tachycardia with early access to the His-Purkinje system is on the differential but is not included in this list.
In this review, we advise against pattern recognition and memorization of diagnostic algorithms, and instead encourage the reader to adapt a deeper understanding of the key mechanistic features for each arrhythmia. When approaching an unknown tracing, the reader should attempt to play out each mechanism to determine which arrhythmias can be excluded from the differential diagnosis list. We provide a number of tools to help clinicians with this exercise.
A Practical Approach to Svt Mechanisms
Mechanisms of arrhythmia generally fall into 4 types: automaticity, triggered activity, microreentry, and macroreentry. The first two are distinguished
biochemically, whereas microreentry refers to a small (generally < 2cm>focal arrhythmias because they originate from a “point source”. This is distinguished from macroreentry, which is an identifiable circuit that allows a propagating impulse to repeatedly reexcite tissue - a common example is atrial flutter, which is a macroreentry circuit in the atria that uses the caval-tricuspid isthmus to re-activate the atria [4].
Atrial tachycardia (AT) refers to mechanisms of arrhythmia that are entirely contained within the atria (Figure 2A).
Figure 2 – A: Atrial Tachycardia mechanism is contained within the atrium. This diagram illustrates focal atrial tachycardia as an example. B: AV Nodal Reentrant Tachycardia (AVNRT) is a macroreentry circuit contained within the AV node. AVNRT does not require the atria or ventricles to sustain. This example demonstrates typical AVNRT with anterograde slow and retrograde fast pathways – note the simultaneous activation of atria and ventricles (in parallel) once the signal exits the slow pathway C: Atrioventricular Reentrant Tachycardia (AVRT) is a large macroreentry circuit, involving the accessory pathway, atrium, AV node, and ipsilateral bundle branch, and ventricular myocardium as part of its circuit.
The classic example is a focal atrial tachycardia, which originates from a point source within the atria. For simplicity, we consider atrial flutter to also fall into the category of AT because it is a macroreentry circuit that is entirely contained within the atria. Other common examples include sinus tachycardia and sinoatrial reentry tachycardia. All these mechanisms are non-AV node dependent, which means that a block in the AV node, either spontaneous or with administration of adenosine, is not expected to terminate the tachycardia since the mechanism does not require conduction through the AV node. AV Nodal Reentrant Tachycardia (AVNRT) is a macroreentry circuit where the obligatory component of the circuit is entirely confined to the compact AV node (Figure 2B). This circuit classically does not require the atrium or ventricles to sustain the tachycardia, and numerous examples
have been observed where AVNRT continues despite a conduction block to the atrium or ventricles5. Published case reports suggest that some AVNRT circuits do involve and require some atrial tissue [6]. AVNRT can be typical (tAVNRT), with an anterograde slow-pathway component, and a retrograde fast-pathway component – aka slow-fast AVNRT. Atypical AVNRT (aAVNRT) includes fast-slow and slow-slow configurations of the circuit, which are far less common. It is important to recognize that in tAVNRT the impulse travels antegrade via the slow pathway, and then simultaneously travels retrograde up the fast pathway to activate the atria as well as down the bundle of His to activate the ventricles. Conduction to both atria and ventricles occurs in simultaneously in parallel, which explains why the V-A time in tAVNRT is characteristically short. In fact, P-waves are often buried within the QRS, or can be seen in the tail end of the QRS (Figure 3C) – the so-called “pseudo-R prime” in V1. The simultaneous activation of atria are ventricles lead some clinicians to refer to it as an “A-on-V tachycardia”. In contrast, aAVNRT generally displays variable ventriculo-atrial (V-A) times and is often impossible to distinguish from AVRT and AT on surface ECG tracings on the basis of V-A relationship.
Atrioventricular Reentrant Tachycardia (AVRT) is a macroreentry arrhythmia with a large circuit that most commonly involves an accessory pathway (AP), atria, AV node, His bundle, ipsilateral bundle branch, and ventricular myocardium close to the AP (Figure 2C). This arrhythmia requires all the above structures, and conduction block in any of those structures would terminate or alter the arrhythmia circuit. Different variations of APs have been described, and we urge advanced learners to review them
Junctional Tachycardia (JT) is caused by an automatic circuit within the AV junction. Each beat of junctional tachycardia usually produces a retrograde P-wave and a QRS of supraventricular morphology. Just like in tAVNRT, conduction to the atria and ventricles occurs simultaneously in parallel, which manifests as a very short V-A interval. The relationship of P-wave and QRS depends on the location of the circuit and the relative conduction times to the atria and ventricles, but generally this will be an A-on-V tachycardia where the P-wave is within or just adjacent to the QRS.
The Search For P-Waves
The key to interpreting a narrow complex tachycardia lies with the identification of P-waves. Learners must train their eyes to recognize P-waves, which manifest as high frequency deflections that are outside the limits of the QRS. They can be easily distinguished from T-waves by their frequency: P-waves are sharper than T-waves because depolarization occurs faster than repolarization.
The presence of sinus beats allows readers to template the normal T-wave and compare it to the one in the tachycardia to detect any superimposed P-waves (see Figure 3A – Compare T-waves of the QRS1 and QRS2). Clinicians should avoid identifying P-waves within the limits of the QRS since parts of the QRS can mimic P-waves and are impossible to distinguish. Each time a candidate P-wave is identified, two candidate P-waves must be calipered to determine if an additional P-wave is hidden halfway. This reduces likelihood of missing 2:1 AV arrhythmias, commonly atrial flutter. Finally, it is important to note that many NCT tracings do not have visible P-waves, and the ability to narrow the differential diagnosis may be limited. Learners should search through tracings for other tools, such as the ones outlined in this review.
Diagnostic Tools
THE ONSET
The onset of an SVT can be somewhat helpful in determining the mechanism of the tachycardia. Most SVTs initiate with a premature atrial contraction followed by PR prolongation (Figure 3A), except for JT. PR prolongation itself is unhelpful because it can represent physiologic decrement in the AV node in response to a PAC, and is compatible with AT, AVNRT and AVRT. However, absence of decrement on the initiating PAC suggests that the slow conduction in the AV node is not required for the initiation of the tachycardia and helps exclude AV-node dependent macroreentry circuits - AVNRT and AVRT (Figure 3B).
Initiation with a PVC generally favours atypical AVNRT (aAVNRT) or AVRT. In AVRT, the PVC blocks in the AV node, conducts up the AP to the atrium, and re-enters the AV node anterogradely to complete the circuit. In aAVNRT, the PVC pe netrates the AV node retrogradely, finds the fast pathway refractory, which takes longer to recover than the slow pathway, allowing the stimulus to travel up the slow pathway retrogradely and re-enter the fast pathway to complete a cycle of atypical fast-slow AVNRT (Figure 3C). Finally, initiation with a ventricular event is very uncommon for AT, hence we can often rule out that possibility.
The onset also allows assessment of the ventricular-atrial (VA) time to determine presence of VA linking. In AT and JT, the first few P-waves in the tachycardia are not mechanistically linked to the timing of the previous QRS, unlike in AVNRT and AVRT. Therefore, presence of V-A linking, as in Figure 3A, suggests the diagnosis of AVNRT/AVRT and helps to exclude AT/JT, except if V-A appears linked by coincidence7. By contrast the tachycardia in Figure 3B does not demonstrate VA linking (measure from onset of QRS to P-wave) – some clinicians consider that this favours AT, but this can be compatible with any mechanism.
Figure 3A – Initiation of tachycardia with a long PR interval. Note the T-wave of QRS2 has a high-frequency component that is absent in QRS1, which suggests the presence of a P-wave (P3). The PAC labeled P3 initiates the tachycardia with a long PR interval. This finding does not help narrow the differential diagnosis. This tracing demonstrates VA linking (see text for details - Diagnostic Tools: The Onset). The VA is measured from the onset of QRS to onset of P-wave. This interval is fixed, suggesting that the first atrial activation (P3) is linked to the last QRS (QRS2), which helps rule out atrial tachycardia unless this happened by coincidence.
Figure 3B – PAC initiates the tachycardia without PR prolongation. This suggests that the delay in the AV node is not required for the tachycardia, and suggests against macroreentry involving the AV node, as in AVNRT and AVRT. Note VA linking is absent, favouring the diagnosis of AT. The VA time is measured from onset of QRS (i.e. QRS2) to onset of P-wave (i.e. P3) on tachycardia initiation, and compare it to the QRS3-P4 and QRS4-P5 intervals.
Figure 3C – Initiation with PVC favours atypical AVNRT and AVRT. The ladder diagram illustrates the mechanism for initiation of fast-slow atypical AVNRT.
Figure 4 – (A) Termination on a P-wave helps rule out AT, especially if observed multiple times. (B) Termination on a ventricular activation with a missing P-wave helps rule out JT.
Finally, the presence of a ramp-up and ramp-down phenomenon (aka non-paroxysmal) favours automaticity as the underlying mechanism of the tachycardia, which supports the diagnosis of AT or JT. Often, gradual changes in cycle length should prompt the clinician to consider sinus tachycardia as the mechanism, since the sinus node is heavily regulated by the autonomic nervous system.
Termination
The termination of the tachycardia can offer some important clues. Termination with an absent P-wave in the last cycle helps exclude AT. If an AT were to end on a P-wave (Figure 4A), then this P-wave must block in the AV node at the same time that the tachycardia mechanism terminates. This requires two isolated events to occur in two independent cardiac structures – atrium and AV node, which unlikely unless by pure chance. Similarly, JT would be unlikely if the last cycle is missing a P-wave (Figure 4B) because it would require a coincidental block from the JT focus to the atria on the same cycle that the JT stops. Seeing this type of termination more than once would help reduce likelihood of this being a coincidental finding.
Av Relationship
Once P-waves are identified, a clinician can use the AV relationship as an extra tool. A very short VA time suggests tAVNRT, and rules out AVRT.
Note that orthodromic AVRT requires activation of the ventricles before re-engaging the AP, which normally occurs apex-to-base. This means that the AP will not be engaged until most of the ventricles are activated, and the VA time in Figure 5A is too short to be AVRT. Although the exact cut-off was not defined in literature on surface tracings, a general cutoff value of 70ms is used [8]. Therefore, Figure 5A most likely represents tAVNRT, but AT with a long PR interval is possible, but far less common. Note that only very short AV times, the so-called A-on-V tachycardias, are helpful because they can exclude AVRT and bring tAVNRT/JT to the top of the differential. In adults, JT is uncommon, hence a very short VA tachycardia is often assumed to be tAVNRT. Any other AV relationship still carries the same differential diagnosis: aAVNRT, AVRT, AT, JT. For this reason, we find classifying NCTs as long-RP or short-RP does not help because both have the same differential diagnosis.
Variation in the tachycardia cycle length can also be helpful. If variation is detected, the clinician should caliper each QRS and candidate P-waves to determine which moves first (Figure 5B). In AT, the P-waves lead QRSs – AT can be ruled out if QRS leads the P wave. Conversely, if the P-wave moves first and leads the QRS, it is compatible with all SVT mechanisms, and nothing can be ruled out except for VT.
Figure 5 – AV Relationship – (A) Templating QRS1 to QRS3 - 6 reveals the presence of a pseudo-R’, which is a P-wave buried in the terminal portion of the QRS. This reveals a very short VA tachycardia, which excludes AVRT. This is a classic tAVNRT, which is common. Differential also includes AT over a slow pathway, but it is far less common. (B) ‘Wobble’ in the tachycardia cycle length reveals QRS complexes leading the P-waves, which rules out AT. Readers should caliper each QRS and P-wave and confirm that the QRS moves first. This is a similar concept to VA linking, which is demonstrated on this tracing.
It is important to note that a 12-lead ECG of the arrhythmia provides additional leads, which can help identify P-waves. The best leads to find the P-wave vary with each patient, but generally are the leads with the smallest QRS, anatomically proximal to the atria, and have the direction congruent with the vector of atrial activation. These are usually V1-V2, I, II, III, aVF.
The P-wave morphology in tachycardia on a 12-lead ECG can help identify the general direction of atrial activation. A retrograde P-wave activates the atrium in a low-to-high direction, registering as a negative deflection in the inferior leads. A high-to-low or left-to-right P-wave would not be compatible with arrhythmias that activate the atria from the AV node - JT and AVNRT.
We present a thoughtful approach to the diagnosis of narrow QRS tachycardia on a surface ECG. This method involves classifying the problem as a “narrow complex tachycardia”, creating a differential diagnosis list, and narrowing the differential by excluding items that are incompatible with the tracing. The tools illustrated in this figure include using the initiation, termination, AV relationship, variation in cycle length and P wave morphology. This approach allows the application of each SVT mechanism to diagnose arrhythmia and may be more intuitive to learners than memorization of diagnostic algorithms.
PAC – Premature Atrial Contraction; NCT – Narrow Complex Tachycardia; WCT – Wide Complex Tachycardia; AVNRT - AV Nodal Re-entrant Tachycardia; AVRT - Atrioventricular Re-entrant Tachycardia
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
