Specificity of electrocardiographic criteria for the. Spontaneous wide qrs complex rhythm in a patient with wide. Approximately 80% of all wide qrs complex tachycardias turn out to be ventricular tachycardia vt. However, an arrhythmia arising from the atria or the atrioventricular junction will produce a broad complex if associated with ventricular preexcitation or bundle branch block. Wide qrscomplex tachycardia with variable vaconduction. Supraventricular tachyarrhythmias harrisons principles.
The mechanism of bidirectional tachycardia pdf free download. Misdiagnosis in patients with aberrant or accessory pathway conduction was also common. Aug 18, 2007 wide complex tachycardias wcts are also known as broad complex or wide qrs complex tachycardias. If regular narrow complex, consider adenosine wide qrs. Wide refers to a qrs complex duration width of greater than or equal to 0.
Only 39 of 122 patients with ventricular tachycardia were correctly diagnosed initially. The differential diagnosis of that tachycardia includes supraventricular tachycardia with aberrancy, bundle branch reentrant ventricular tachycardia, and. They are written by uk doctors and based on research evidence, uk and european guidelines. Wide complex tachycardias the differential diagnosis. Figure 1 episode of a wide complex tachycardia with a right bundle branch block rbbb configuration, which spontaneously changes to a narrow complex svt in the presence of a slight decrease in cycle length. In others, the diagnoses were supraventricular tachycardia with aberrant conduction 43 of 122 or simply a wide qrs tachycardia 40 of 122. A scoring algorithm for the accurate differential diagnosis. Wide qrs complex tachycardia is defined as a heart rate of 100 bpm and qrs duration of 120 ms. Apr 28, 2020 narrow complex tachycardia must have a qrs duration less than 0. After this run there is a change to a narrow qrs complex. The differential diagnosis of that tachycardia includes supraventricular tachycardia with aberrancy, bundle branch reentrant ventricular tachycardia, and preexcited. Correct diagnosis in wide qrs complex tachycardia remains a challenge.
Management strategies in wide qrs complex tachycardia. Cureus electrical cardioversion for wide complex tachycardia. Thus, the first consideration should be atrial fibrillation with wpw preexcited af, and this was my first impression. It is speculated that these relatively rare cases of narrow complex ventricular tachycardia utilize the hispurkinje system as part of the tachycardia circuit. Differentiating types of widecomplex july 2015 tachycardia. The tracing of figure 1 leads ii, iii, and v1 taken simultaneously has been recorded from a 58yearold man during the recovery phase of exercise stress testing. The patient returned to normal sinus rhythm after being cardioverted with 100 joules j on the first attempt. Please note that the retrograde p wave is seen slightly after the qrs complex pseudo r wave in lead v1 and the pseudo s wave in leads ii, iii, and avf, which suggest typical.
Most produce narrow qrs complex tachycardia qrs duration wide qrs complex during supraventricular tachycardia that must be distinguished from. The v i is measured in that lead where a bi or multiphasic qrs complex is present and the initial ventricular activation is the fastest, and in that particular lead that qrs complex is chosen for the measurement of v i and v t where the onset and end of the qrs are clearly visible. New algorithm using only lead avr for differential. Seven of the 16 criteria analyzed had ppvs 95%, and each criterion was assigned a score. Surface leads i, ii, iii, avf, v1 and v6, and electrograms recorded from the right ventricular apex and the coronary sinus. Consider adenosine only if regular and monomorphic. The differential diagnosis on the electrocardiogram. Wide qrs complex tachycardia wct may be a ventricular tachycardia vt or a supraventricular tachycardia svt with intraventricular conduction disturbance or with a preexcitation.
Adult tachycardia wide complex sec regular rhythm ac 7 any local ems system changes to this document must follow the nc oems protocol change policy and be approved by oems single lead ecg able to diagnose and treat arrhythmia 12 lead ecg not necessary to diagnose and treat, but preferred when patient is stable. Introduction two ecg features define widecomplex tachycardia. If the arrhythmia is a widecomplex tachycardia, it needs rapid decisionmaking and treatment in order to avoid further deterioration. Shown are surface ecg leads i, avf and v1, and intracardiac recordings from hisbundle electrogram hbe 1,2 to hbe 5,6, and right ventricular apex rva. A wide complex tachycardia may represent either vt 80% or a supraventricular rhythm with aberrant conduction 20%. However, due to its potential lifethreatening nature, emergency clinicians must know how to assess and manage this condition. It is important to keep in mind that a good estimate of vt versus svt can be. You may find one of our health articles more useful. The elucidation of the mechanism of wct is vital not only for acute arrhythmia management, but also for the further workup, prognosis and chronic management. Wide complex tachycardia is a rare disease entity among patients presenting to the emergency department. It is easiest to understand this nomenclature by considering these terms independently. Mar 23, 2002 if the tachycardia originates in the proximal part of the hispurkinje system, however, duration can be relatively shortas in a fascicular tachycardia, where qrs duration ranges from 0.
Differential diagnosis between ventricular and supraventricular tachycardia has important therapeutic and prognostic implications, and although data from clinical history and physical examination may suggest a particular origin, it is the 12lead surface electrocardiogram that usually enables this differentiation. We present a case of electrical cardioversion used to treat a hemodynamically unstable wide complex tachycardia wct. Accahaesc guidelines for the management of patients with. During wide complex tachycardia heart rate 100min, qrs 0. Application of a new algorithm in the differential diagnosis. Arriving at the correct diagnosis in cases of wide complex tachycardia remains problematic for many clinicians. It is usually a regular, wide complex tachycardia with a rate between 120 and 250 beats per minute. P waves are normal, rhythm is regular and rate is usually less than 220 per. In the emergency setting most broad complex tachycardias have a ventricular origin. Current algorithms for the diagnosis of wide qrs complex.
Jul 18, 20 tachycardias are broadly categorized based upon the width of the qrs complex on the electrocardiogram ecg. Making the correct diagnosis is important for the acute as well as long term management of patients with wct. There is also a group of wide complex tachycardias caused by toxic metabolic syndromes that is discussed. The wide qrs tachycardia annals of internal medicine. The acute management of a regular narrow qrs complex tachycardia will depend on the hemodynamic state of the patient. The differential diagnosis of wideqrs tachycardias ecg. Acls tachycardia algorithm for managing stable tachycardia. Wide complex tachycardia ventricular tachycardia or not. But there are sections of wide complex regular monomorphic rhythm within the tracing. Wide qrs complex tachycardia the ecg in prehospital. Wide qrs complex tachycardia can be originated by 3 main mechanisms 1. It reveals a wide qrs complex tachycardia that is mainly regular, with a qrs duration of 180 milliseconds. A relatively common frustrating and anxietyprovoking situation in medical practice is the confrontation of a physician with a wide qrs complex tachycardia wct ecg tracing.
The value of electrocardiography for differential diagnosis. When doubt exists in an emergency situation, it is safest to assume that a wide complex. The first 2 beats are sinus, whereas the third qrs complex starts a tachycardia with an average rate of about 160 beatsmin. Approach to wide complex tachycardias in patients without. Ashmans phenomenon a source of nonsustained widecomplex tachycardia. Tachycardia with wide qrs complex in a patient with. The correct diagnosis of a wide complex tachycardia wct qrs duration 120 msremains a challenge despite numerous established criteria for the differentiation of ventricular from supraventricular tachycardia svt with aberrant conduction.
It reveals a wideqrs complex tachycardia that is mainly regular, with a qrs duration of 180 milliseconds. Supraventricular tachycardia svt with an aberrant conduction attributable to a preexisting bundlebranch block or functional bundlebranch block induced by the fast heart rate. Wide complex tachycardiadiagnostic approachalgorithms sen. Several algorithms have been developed to aid in this differentiation below. In much the same way, an irregular wide complex tachycardia is almost always from a patient who has a baseline ekg with a wide qrs complex who then develops an irregular tachycardia e.
Wide qrs complexes not typical ofright or left bundle branch block and tall peaked t waves more vertical on their upstrokes than their downstrokes suggest hyperkalemia. However, criteria do not as yet exist to discriminate between ventricular tachycardia and supraventricular tachycardia with anterograde conduction over an accessory pathway preexcited tachycardia. The ecg in figure 1 shows a wide qrs complex tachycardia at 170 bpm. May 14, 2015 professional reference articles are designed for health professionals to use. Pdf specificity of electrocardiographic criteria for the. Wide qrs complex tachycardia annals of internal medicine. Brugada p, brugada j, mont l, smeets j, andries ew 1991 a new approach to the differential diagnosis of a regular tachycardia with a wide qrs complex. The correct differentiation between a supraventricular and ventricular origin of a wide qrs tachycardia is of obvious diagnostic, therapeutic, and prognostic importance. The 12lead surface electrocardiogram ecg is a useful tool to identify ventricular tachycardia vt in the differential diagnosis of wide qrs complex tachycardia wct.
Management requires advanced knowledge of ecg and rhythm. And third, if atrial fibrillation develops, then it will manifest as this dangerous wide complex tachycardia. Wide complex tachycardia encompasses a range of cardiac dysrhythmias, some. While these features of the av relationship are attractive, it is often difficult to discern clear atrial activity during wct, or the presence of atrial fibrillation or flutter confounds the issue. The intracardiac signal during the latter confirmed that it was a ventricular tachycardia vt figure 2 b va dissociation, without anterograde his potential. Management and treatment for a stable tachycardia with a wide qrs complex and either a regular or irregular rhythm should be done in the hospital setting with expert consultation available. On the diagnosis of wide qrs tachycardia springerlink.
When confronted with a tachycardia having a broad qrs complex, it is important to be able to differentiate between a supraventricular and a ventricular tachycardia. He was admitted to the hospital for cardiac evaluation and ultimately discharged home on flecainide and nebivolol after a negative cardiac workup. The pharmacologic and nonpharmacologic antiarrhythmic approaches discussed may, therefore, include some accahaesc guildelines 1859. Any impulses generated in the ventricles will result in wide qrs complexes because. A tachycardia is defined as a heart rate greater than 100 beats per minute bpm. When doubt exists in an emergency situation, it is safest to assume that a wide complex tachycardia is vt. A narrow qrs complex tachycardia qrs duration 100 bpm indicates a supraventricular origin with ventricular activation occurring via the fastconducting hispurkinje system. The differential diagnosis of a regular, monomorphic wide qrs complex tachycardia wct mechanism represents a great diagnostic dilemma commonly encountered by the practicing physician, which has important implications for acute arrhythmia management, further workup, prognosis and chronic management as well. Wide qrs complex tachycardia of uncertain origin in patients with stable wide qrs tachycardia of uncertain origin, adenosine and lidocaine previously were recommended. Brugadas criteria is based on the standard 12lead ecg, but additional leads and techniques may aide in diagnosis.
It may be of supraventricular or ventricular origin, and differential diagnosis between the two has important therapeutic and prognostic implications. Association of bidirectional ventricular tachycardia with familial sudden death syndrome wide complex tachycardia. Comparison of five electrocardiographic methods for. The qrs complex in ventricular tachycardia often has a right or left bundle branch morphology. Broad complex tachycardias occur by various mechanisms and may be ventricular or supraventricular in origin. If the tachycardia has a wide complex qrs and is stable, consult with an expert. A higher percentage of patients with vt had structural heart disease 86. As in the baseline ecg, runs of wide qrs complex tachycardia with left bundle brunch morphology lbbb interacting with the narrow qrs tachycardia were also observed. The insertion of the accessory pathway in the free wall of the right ventricle results in sequential right to left ventricular activation and a wide qrs complex. Representative example of wide qrs complex tachycardia due to supraventricular tachycardia is shown when the initial as well as the terminal 40 ms of the qrs complex in lead avr displayed both positive and negative deflections and the sum of their absolute values disregarding polarity were used as the values of v i and v t.
The vast majority of wcts originate from impulses generated in the ventricles ventricular tachycardia being the most common arrhythmia. The crossing points of the vertical lines with the qrs. Tachycardias are broadly categorized algorithm 1 based upon the width of the qrs complex on the electrocardiogram ecg. This ecg shows a wide complex tachycardia which is overall irregular and has qrs complexes with differing morphology. Overall, this is a consensus document that includes evidence and expert opinions from several countries. Wide qrs complex tachycardia in an apparently healthy man. Medication given for the treatment of a supraventricular tachycardia svt may be harmful to a patient with a ventricular tachycardia vt. Before giving any antiarrhythmic medication, attempts should be made to determine the origin of the tachycardia. Simple electrocardiographic criteria for rapid identification. Tachycardias are broadly categorized based upon the width of the qrs complex on the electrocardiogram ecg. We recently sincronizadaa an ecg algorithm for differential diagnosis of regular wide qrs complex tachycardias that was superior to the brugada algorithm. Specificity of electrocardiographic criteria for the differential diagnosis of wide qrs complex tachycardia in patients with intraventricular conduction defect.
Capitalizing on the fact that in svta the electrical vectors move rapidly at the beginning of the qrs and more slowly at the end activating the locked ventricle, whereas in vt slow conduction is the rule throughout the qrs complex, vereckei and colleagues recently reported a new criterion that quantifies these differences. Diagnosis and management of narrow and wide complex. Wide qrscomplex tachycardia with right bundle branch morphology at a cycle length of 430 ms. In this issue, stewart and colleagues 1 present a rather gloomy picture of the diagnostic ability of physicians initially managing patients with a wide qrs tachycardia. The presence of predominantly negative qrs complexes in leads 1,2,3 is suggestive of vt this is another way to describe right superior axis similar to rs axis it is considered as highly specific for vt 15. In the first part of the tracing a broad qrs tachycardia is shown, with lbbb inferior axis morphology and negative qrs complex in avl. At tachycardia onset, the rr interval is relatively long but shortens over the course of the first few beats. Simultaneous wide and narrow qrs complex tachycardia. This patient will have a history consistent with a known cause that requires compensation. Wide qrscomplex tachycardia wct may be a ventricular tachycardia vt or a supraventricular tachycardia svt with intraventricular conduction disturbance or with a preexcitation. In the differential diagnosis of a tachycardia with a wide qrs complex greater than or equal to 0. The av relationship is independent of complicated morphological criteria as well as the pattern of the patients qrs complex during normal rhythm. The clinical tachycardia in figure 1 is a regular wide qrs complex tachycardia at 188 bpm, showing left bundle branch block morphology, left superior axis, and late precordial qrs transition at lead v6. Application of a new algorithm in the differential diagnosis of wide qrs complex tachycardia.
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