An Aproach to Differential

Diagnosis of Wide QRS

Complex Tachycardias

Sedat Köse,MD,

30.06.2012 Trabzon/TURKEY

DefinitionDefinition

•• Heart rate > 100/minHeart rate > 100/min

•• QRS duration QRS duration ≥≥ 120 ms120 ms

EtiologyEtiology

•• SVT + aberrationSVT + aberration

•• SVT + preSVT + pre--existing BBBexisting BBB

•• SVT + preSVT + pre--excitation excitation

(Antidromic tachycardia)(Antidromic tachycardia)

Ventricular

Supraventricular

•• Ventricular tachycardiaVentricular tachycardia

•• Ventricular pace rhythmVentricular pace rhythm

SVT: supraventicular tachycardia

SVTSVT with awith aberraberrant nt conductionconduction

Antidromic Antidromic tachycardiatachycardia

VT

Differential Diagnosis ToolsDifferential Diagnosis Tools

•• General informationGeneral information

•• History and physical examinationHistory and physical examination

•• Electrocardiography (ECG)Electrocardiography (ECG)

General informatonGeneral informaton

VT ; 80VT ; 80

Aberrant conducted SVTs; 15Aberrant conducted SVTs; 15--30% 30%

PrePre--excited tachycardies ;1excited tachycardies ;1--5%5%

History and physical examinationHistory and physical examination

•• Predictive value of prior medical history Predictive value of prior medical history for VTfor VT

�� myocardial infarction myocardial infarction 98%98%

�� Congestive heart failure Congestive heart failure 100%100%

�� Recent angina pectoris Recent angina pectoris 92%92%

* Baerman JM, Morady F, DiCarlo LA Jr, de Buitleir M. Differentiation of ventricular tachycardia from

supraventricular tachycardia with aberration: value of the clinical history. Ann Emerg Med. 1987; 16(1):40-3.

HistoryHistory

• Age ≥ 50

• Presence of MI, CHD, KAH, structural heart disease

• History of VT

•• Age Age ≤ 35

•• Absence of structural heart Absence of structural heart diseasedisease

•• History of SVTHistory of SVT

VT

SVT

Physical examinationPhysical examination

VTVT SVTSVT

Juguler canon A waveJuguler canon A wave ++ --

Variability of arterial Variability of arterial pressurepressure

++ --

Alternation of 1st heart Alternation of 1st heart soundsound

++ --

Hemodynamic instability Hemodynamic instability +/+/-- +/+/--

•• To date, different algorithms have been To date, different algorithms have been

developed for the differantiation of VT and developed for the differantiation of VT and

SVT.SVT.

�� Classical Classical ‘‘WellensWellens’’ criteria, 1978criteria, 1978

�� Brugada algorithm, 1991Brugada algorithm, 1991

�� The aVR The aVR ‘‘VereckeiVereckei’’ algorithm, 2007 algorithm, 2007

�� ……

ECG algorithmsECG algorithms

Classical Classical ‘‘WellensWellens’’ criteriacriteria

* Wellens HJ, Bar FW, Lie KI. The value of the electrocardiogram in the differential diagnosis of a tachycardia with a widened QRS complex. Am J Med 1978;64: 27–33.

AV dissociationAV dissociation

22

Brugada algorithmBrugada algorithm

* Brugada P, Brugada J, Mont L, Smeets J, Andries EWI. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation 1991;83:1649.

Positive concordancePositive concordance

Negative concordanceNegative concordance

The aVR The aVR ‘‘VereckeiVereckei’’ algorithmalgorithm

•• Vereckei et al defined two algorithm in 2007 Vereckei et al defined two algorithm in 2007 and 2008.and 2008.

∗ Vereckei A, et al. Application of a new algorithm in the differential diagnosis of wide QRS complex tachycardia. Eur Heart J 2007;28:589–600.

∗ Vereckei A, et al. New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia. Heart Rhythm 2008;5:89–98.

A = Vi

B = Vt

Vi/Vt <1

VereckeiVereckei’’s 2007 algorithms 2007 algorithm

VereckeiVereckei’’s 2008 algorithms 2008 algorithm

Vereckei, A. et al. Eur Heart J 2007 28:589-600

VT with aVR initial R

Vereckei, A. et al. Eur Heart J 2007 28:589-600

Vi/Vt criteria

Vi/Vt>1 SVT

Vi/Vt<1 VT

Limitations of AlgorithmLimitations of Algorithm

�� BundleBundle--branch reentrant VT branch reentrant VT

�� Fascicular VT Fascicular VT

�� Atriofasciculer accessory pathway dependent SVTAtriofasciculer accessory pathway dependent SVT

Vereckia et al.Heart Rhythm 2008;5:89Vereckia et al.Heart Rhythm 2008;5:89--9898

DII: RDII: R--wave peak timewave peak time

SMVT

Sğ.PS.C

ILVT ILVT

L.AL.C

AVNRT

ConclusionConclusion

�� By using all ECG criteria,underliying causes of regular wide QBy using all ECG criteria,underliying causes of regular wide QRS RS complex tachycardia is still misdiagnosed in up to 10 % of paticomplex tachycardia is still misdiagnosed in up to 10 % of patients ents

�� It seems prudent to consider and treat all sustained WCT as VT It seems prudent to consider and treat all sustained WCT as VT unless the diagnosis of SVT can be definitively established.unless the diagnosis of SVT can be definitively established.

�� EP study is essential for the definitive diagnosisEP study is essential for the definitive diagnosis