Tachycardia starts with an enddiastolic wide qrs complex occurring shortly after a sinus p wave from. He was admitted to the hospital for cardiac evaluation and ultimately discharged home on flecainide and nebivolol after a negative cardiac workup. Pdf the differential diagnosis of a regular tachycardia. The morphology of qrs complex was similar in tachycardia and sinus rhythm, suggesting supraventricular tachycardia. Broad qrs complex tachycardias bcts are also known as wide qrs complex tachycardias wcts.
Introduction two ecg features define wide complex tachycardia. Ecg of the month, report by the journal of the louisiana state medical society. Acls tachycardia algorithm for managing stable tachycardia. When the qrs complex during tachycardia is identical to the qrs complex in sinus rhythm, bundle branch ventricular tachycardia bbvt is a likely diagnosis, in particular when the involvement of the purkinje system in the antegrade axis of the tachycardia can be established, for example, changes. Jul 18, 20 tachycardias are broadly categorized based upon the width of the qrs complex on the electrocardiogram ecg. Using the acls tachycardia algorithm for managing stable tachycardia. It has been observed that whenever, in a wide qrs complex tachycardia, the interval from qrs complex beginning to s wave nadir exceeds 100 ms in a precordial lead, tachycardia is ventricular in origin. Intraventricular conduction delay can result from heart rate changes, as well as from fixed pathological lesions in the conduction system. 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. Commentary as observed in figure 1b, the induced tachycardia shows rightbundlebranchblock morphology and beattobeat. 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. A wide complex tachycardia wct is simple enough to define.
Wolffparkinsonwhite syndrome the most important clinical feature when treating patients with bct is their haemodynamic status. I3 in dealing with a wide qrs complex tachycardia, it is im portant to decide whether it is ventricular tachycardia vt, supraven. The differential diagnosis of a regular tachycardia with a wide qrs complex on the 12lead ecg. Vt usually presents with wide qrs tachycardia because it originates in ventricular myocardium, travels muscle to muscle instead of the normal conduction system. Application of a new algorithm in the differential diagnosis of wide qrs complex tachycardia. The most common types of supraventricular tachycardia are caused by a reentry phenomenon producing acceler ated heart rates. The differential diagnosis of a nct is given in table 1. Check the full list of possible causes and conditions now. When confronted with a wide qrs complex tachycardia it can be difficult to differentiate between a supraventricular tachycardia with aberrancy or ventricular tachycardia.
Classification of tachycardias with a broad qrs complex. Polymorphic ventricular tachycardia vtach polymorphic vtach is a type of vtach where there are multiple foci present in the ventricle conducting depolarization. A wide complex tachycardia may represent either vt 80% or a supraventricular rhythm with aberrant conduction 20%. 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. Current algorithms for the diagnosis of wide qrs complex ncbi. Several algorithms have been developed to aid in this differentiation below. Although i agree with most of their conclusions, i must take issue with two points. Wide qrs complex tachycardia in the emergency setting. When there is doubt, wide qrs tachycardia should prompt specialist consultation or be considered ven. Approach to wide complex tachycardias in patients without. Wide qrs complex tachycardia can be originated by 3 main mechanisms1. Ann arbor, michigan case presentation a 78yearold man underwent an electrophysiologic procedure because of a 25year history of.
Wideqrs complex tachycardia american journal of cardiology. A new approach to the differential diagnosis of a regular tachycardia with a wide qrs complex. Consider adenosine only if regular and monomorphic. Wide qrscomplex tachycardia annals of internal medicine. The aim of this study was to compare the ability of two fourstep algorithms brugada and vereckei to diagnose wide complex tachycardias, since the differential diagnosis of this. Lim s l, teo s g, kireyev d, poh k k case 1 clinical presentation an 88yearold man presented with a oneweek history of shortness of breath and intermittent palpitations.
An electrocardiogram ecg is used to classify the type of tachycardia. In this case, we have a patient whos in ventricular tachycardia, widecomplex ventricular tachycardia. During wide complex tachycardia heart rate 100min, qrs 0. Mar 01, 2001 wide qrs complex tachycardia is a common arrhythmia in clinical practice and often presents a diagnostic challenge. We present a case of electrical cardioversion used to treat a hemodynamically unstable wide complex tachycardia wct. The differential diagnosis of wide qrs complex tachycardia. Tachycardias are broadly categorized based upon the width of the qrs complex on the electrocardiogram ecg. When doubt exists in an emergency situation, it is safest to assume that a wide complex. Application of a new algorithm in the differential diagnosis. The pharmacologic and nonpharmacologic antiarrhythmic approaches discussed may, therefore, include some accahaesc guildelines 1859. Diagnosis and treatment wide qrs complex tachycardias may be either from ventricular or from supraventricular. In the clinical setting, the distinction between narrow and wide complex tachycardia supraventricular vs.
First, lets start with monomorphic widecomplex tachycardias. They may be classified into narrow and wide complex based on the qrs complex. Wide qrs complex tachycardia wct may be a ventricular tachycardia vt or a supraventricular tachycardia svt with intraventricular conduction disturbance or with a preexcitation. This 12lead ecg and lead v 1, ii, and v 5 rhythm strip shows a narrow complex tachycardia at a rate of 162 bpm with retrograde p waves in leads ii, iii, avf, and v 1. Irregular narrow qrs complex tachycardia the commonest arrhythmia in clinical practice. 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. At first glance, we always tend to lean toward vt as the cause of a wide complex tachycardia. The differentiation of wide qrs complex tachycardias. 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. Comparison of five electrocardiographic methods for. In the differential diagnosis of a tachycardia with a wide qrs complex greater than or equal to 0. Broad refers to a qrs complex duration of greater than or equal to 0.
With wide complex tachycardia, there is always a chance of ventricular tachycardia, and the patient should be treated as v tach until proven differently. Current algorithms for the diagnosis of wide qrs complex. The patient returned to normal sinus rhythm after being cardioverted with 100 joules j on the first attempt. Clinical research arrhythmiaelectrophysiology application of a new algorithm in the differential diagnosis of wide qrs complex tachycardia andra. Narrow complex tachycardia which is further divided into sinus tachycardia and supraventricular tachycardia and wide complex tachycardia possible ventricular tachycardia narrow complex tachycardia must have a qrs duration less than 0. From the cardiology division, department of internal medicine, university of michigan medical center. May 14, 2015 in broad complex tachycardias the qrs complex is longer than 120 ms three small squares on the ecg.
Wide qrs complex tachycardia can be originated by 3 main mechanisms 1. The ecg criteria for left bundle branch block is met here. Narrow and wide complex tachycardia interventional cardiology. Myths and pitfalls amal mattu, md, facep, faaem professor and vice chair director, emergency cardiology fellowship department of emergency medicine university of maryland school of medicine baltimore, maryland objectives at the conclusion of this presentation, each participant should be able to. June 5, 2009 page 3 of 3 presumed ventricular tachycardia a guideline for patients with wide complex tachycardia of cardiac origin with qrs greater than 0. This ecg shows a wide complex tachycardia which is overall irregular and has qrs complexes with differing morphology.
First, that ventricular tachycardia makes up an overwhelming majority of cases is not definitively answered by a. Clinically significant tachycardias will typically have a rate greater than 150minute. What is the cause of the regular wide qrs complex tachycardia. Initial evaluation and management of widecomplex tachycardia. A supraventricular rhythm originates above the ventricles. If the arrhythmia is a wide complex tachycardia, it needs rapid decisionmaking and treatment in order to avoid further deterioration. But there are sections of wide complex regular monomorphic rhythm within the tracing. Supraventricular tachycardia, ventricular tachycardia, wide qrs complex tachycardia. The article on wide qrs complex tachycardia by akhtar and colleagues 1 is a welcome treatise on the electrocardiographic diagnosis of this complex and often enigmatic arrhythmia. Wide complex rhythms have a qrs duration greater than 0. Thus, the first consideration should be atrial fibrillation with wpw preexcited af, and this was my first impression. Arriving at the correct diagnosis in cases of wide complex tachycardia remains problematic for many clinicians. Wide qrscomplex tachycardia with variable vaconduction. The key to managing a patient with any tachycardia is to assess if pulses are present, decide if the patient is stable or unstable, and then treat the patient based on the patients condition and rhythm.
Wide qrs complex supraventricular tachycardia with negative precordial concordance article by loukas pappas, michalis efremidis, konstantinos p letsas, gerasimos d gavrielatos, ioannis p alexanian, antonios sideris, fotios kardaras. Wide qrs complex tachycardias wct are cardiac rhythm disorders of 3 or more consecutive beats, with rates exceeding 100 beats per minute and a qrsduration of120 milliseconds or greater. Wide qrs complex tachycardia the ecg in prehospital. The above criterion was fulfilled in 41 % of patients with previous myocardial infarction and vt. 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. Accahaesc guidelines for the management of patients with. By incorporating two new criteria, a new, simplified algorithm was devised and compared with. Wide complex monomorphic ventricular tachycardia many wide complex tachycardias originate in the ventricles, but some do not. 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. Wide qrs complex tachycardia of uncertain origin in patients with stable wide qrs tachycardia of uncertain origin, adenosine and lidocaine previously were recommended.
If the morphology changes, if the complex changes its look then wed call that a polymorphic widecomplex tachycardia, and the treatments a little different. Jul 25, 2009 a tachycardia is a heart rate equal to or greater than 100. Wide complex tachycardia ventricular tachycardia or not. This results in qrs complexes of varying size amplitude, axis, and width of qrs complex see example of torsades below. If regular narrow complex, consider adenosine wide qrs. Overall, this is a consensus document that includes evidence and expert opinions from several countries. Making the correct diagnosis is important for the acute as well as long term management of patients with wct.
Any cause of widened qrs complex can result in a sustained or non. If the tachycardia has a wide complex qrs and is stable, consult with an expert. Wide complex tachycardias the differential diagnosis. In a man with a wideqrs complex tachycardia, a history of an inferior left ventricular scar, atrioventricular dissociation during the tachycardia, and a qrs. A wide qrs complex tachycardia what is the mechanism. Ventricular tachycardia, supraventricular tachycardia with aberrant intraventricular conduction, and supraventricular tachycardia with anterograde. Wide complex tachycardias the differential diagnosis remains wide and complex. In others, the diagnoses were supraventricular tachycardia with aberrant conduction 43 of 122 or simply a wide qrs tachycardia 40 of 122. Specificity of electrocardiographic criteria for the. It is usually the central and most visually obvious part of the tracing. Wide qrs tachycardia, brugada algorithm, vereckei algorithm, ventricular tachycardia, supraventricular tachycardia, electrocardiographic diagnosis whats new. Aberrant svt, like a bundle branch block ventricular reentry problem where the ventricles contract too early after partial repolarization like a preexcited tachycardia or wolffparkinson white syndrome a very common ventricular.
Aims the brugada criteria proposed to distinguish between regular, monomorphic wide qrs complex tachycardias wct caused by supraventricular svt and ventricular tachycardia vt have been reported to have a better sensitivity and specificity than the traditional criteria. The major clinical problem that arises when dealing with someone exhibiting a wide complex tachycardia is that it is not always immediately clear if the rhythm. Approach to wide qrs complex tachycardias clinical gate. Only 39 of 122 patients with ventricular tachycardia were correctly diagnosed initially. The differentiation of wide qrs complex tachycardias presents a challenging diagnostic dilemma to many physicians despite multiple published algorithms and approaches. Aug 18, 2007 any cause of a widened qrs complex can result in a sustained or nonsustained wide complex tachycardia if the rate is greater than 100 beats per minute. The 12lead surface electrocardiogram ecg is a useful tool to identify ventricular tachycardia vt in the differential diagnosis of wide qrs complex tachycardia wct.
Ventricular arrhythmias are almost allways wide qrs complex arrhythmias. Pdf current algorithms for the diagnosis of wide qrs. Narrow complex sinus tachycardia, which originates from the sinoatrial sa node, near the base of the superior vena cava. The evaluation and treatment of wide qrscomplex tachycardia remains a challenge, and mismanagement is quite common. Before giving any antiarrhythmic medication, attempts should be made to determine the origin of the tachycardia. Most have a narrow qrs complex, although, occasionally, electrical conduction abnormalities may produce a wide qrs complex that may mimic ventricular tachycardia vt. Initial ecg recording demonstrated wide complex tachycardia wct with irregular heart rate of approximately 180 beats per minute with right bundle branch block. Cureus electrical cardioversion for wide complex tachycardia.
Ventricular tachycardia monomorphic and polymorphic ventricular fibrillation supraventricular tachycardia with aberrant conduction wide qrs complex tachycardia the ecg in prehospital emergency care wiley online library. Correct diagnosis in wide qrs complex tachycardia remains a challenge. Symptoms may include palpitations including possible pulsations in. However, variable va conduction during tachycardia and the finding that the tachycardia was only inducible by ventricular stimulation in a patient with structural heart disease suggest ventricular tachycardia.
As shown in fig 1, broad qrs tachycardia can be divided in three groups svt with bundle branch blockbundle branch block bbb may be preexisting or can occur when the refractory period of one of the bundle branches is reached because of the heart rate of the svt so called tachycardia related or phase 3 block. In a man with a wide qrs complex tachycardia, a history of an inferior left ventricular scar, atrioventricular dissociation during the tachycardia, and a qrs morphology inconsistent with right or left bundle branch block exclude a diagnosis of supraventricular tachycardia with aberrant ventricular conduction due to bundle branch block or ventricular preexcitation and establish a diagnosis of. A narrow qrs complex requires rapid, highly synchronous electrical activation of the right ventricular rv and left ventricular lv myocardium, which can only be achieved through the specialized, rapidly conducting hispurkinje system hps. An unusual wide qrs complex tachycardia what is the mechanism. Application of a new algorithm in the differential. The differential diagnosis of wide qrs tachycardia is challenging. A broad qrs complex is either caused by the ventricular conducting system not working bundle branch block or the electrical circuit not involving the atrioventricular av node correctly. Wide qrs complex tachycardia may be defined as tachycardia having qrs duration of greater than 120 ms 0. Wide complex tachycardia ventricular tachycardia or not ncbi.
Fram thedepartment of internal medicine division of cardiology university of michigan medical center, ann arbor, michigan case presentation a 45yearold woman underwent an electrophysiology procedure because of a 20year history of recunent. The ecg in figure 1 shows a wide qrs complex tachycardia at 170 bpm. What is the cause of qrs and cycle length alternans. Wide complex tachycardia wide complex tachycardia is a cardiac rhythm with more than 100 ventricular beats per minute and a qrs complex of 120 ms or greater. He had a history of ischaemic heart disease with no prior revascularisation. Narrow qrs complex tachycardia nct once a nct is identified the first step is to determine whether the rhythm is regular or irregular. However, vts need not be wide always, if it captures the conduction system early and more proximally it can be as narrow as svt.
Supraventricular tachycardia svt with an aberrant conduction attributable to a preexisting bundlebranch block or functional bundlebranch block induced by the fast heart rate. Oct 05, 2012 wide complex tachycardia features for differentiation. The qrs complex is the combination of three of the graphical deflections seen on a typical electrocardiogram ekg or ecg. Thanks for another challenging wide complex tachycardia. Health, general electrocardiogram usage electrocardiography medical history taking prednisone dosage and administration tachycardia diagnosis patient outcomes. The width of the qrs complex should be verified in all leads, because the qrs complex can often be narrower in 1 or 2 of the 12 leads. Even though ecg criteria have been proposed to identify ventricular origin, this is discouraged when the patient is unstable, and used only with caution in stable conditions 5. Wide complex tachycardia is defined as a cardiac rhythm with a rate greater. Etiologies of various wcts are listed in table 2, with schematic diagrams to better appreciate the conduction pathways and electrophysiology behind wcts provided in figure 1. Wide qrs complex tachycardia annals of internal medicine.