Wide Complex Tacycardia.1

8/4/2019 Wide Complex Tacycardia.1

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Case Presentation

Dr.Ahmad Wali,

Resident Cardiology


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53 years old Female,K/c of HTN,Diabetes presented in cardiacemergency as having history of Chest pain 2 Hrs and thenunconsciousness. BP 80 mm Hg systolic, Pulse Not detected

Patient was given DC shock but she did not survive and expired.


3/31

57 years old male,K/c of HTN,Diabetes presented in cardiacemergency as having Chest pain and Palpitation 2 HrsBP 110 mm Hg systolic, Pulse 70/min

The patient was given Amiodaron infusion and he got sinusRhythm.


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65 years old male diagnosed case of Decompensated HF presentedin cardiac emergency as having Chest pain,S.O.B 1 hrBP 110/80, Pulse 150/min,Bilateral Chest crepts presented.

The patient was given Amiodaron infusion and he gotsinus Rhythm.


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26 years old male who is smoker,alcoholic presented incardiac emergency as having Palpitation 1 hrBP 100/70, Pulse 150/min

The patient was given Amiodaron infusion with no improvementthen given 50 and 100 J DC Shock and he got the followingRhythm.


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All of the above fall in Wide

ComplexTachycardias so the D/Ds are b/w

Ventricular Tachycardia

SVT with aberrancy SVT with underlying bundle branch

block

SVT with pre-excitation(Wolf ParkinsonWhite Syndrome)


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Why it is important to Diagnose Wide complex

tacycardia??? Because correct diagnosis is important both for acute and also for later

management.

To avoid the use of Verapamil which may precipitate hemodynamiccollapse with V.T.

The clinical situation of the patient with WCT is usually serious so youdont have much time to read ECG ,so the criteria must be easilyapplied and easily remembered.

To use ECG criteria for diagnosis

To use presence of risk factors for V.T. as discriminator


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Definitions -WCT :Rate equal or more than 100 and QRS duration of at least 120

msec. -VT :a WCT starting below the level of His bundle.

-SVT : a tachycardia dependent on structures at or above the level ofHis bundle.

-LBBB morphology: QRS duration more than 120 with predominantlynegative terminal deflection in V1.

-RBBB morphology : QRS duration more than 120 and a terminalpositive deflection in V1. -LBBB and RBBB morphology denote the appearance of QRS , without

implying actual His-Purkinje disease.


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Definitions Aberrancy; conduction delay in His purkinji

system during antegrade conduction resulting

in wide QRS. Pre-exitation syndrome-AV conduction can

occure via normal conduction system and viaan accessory AV pathway.


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Wide-Complex Tachycardia If it's a wide complex rhythm (fast or slow) it's

ventricular until proven otherwise!The basic rule for WCT

Majority are sinus tachycardia with bundle branch block

In higher risk population , previous MI, Decreased Leftventricular dysfunction Predominantly Ventricular Tachycardia


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SVT vs VT

History

The majority of patients with VT have structuralheart disease, In SVT they may or may not have.

Patient with VT are older.

'Horizontal entrance' into the ER. Older patient withprevious M.I = most likely VT.

Younger patient with known paroxysmal

tachycardias and who is hemodynamically stable =most like SVT

-Patients with SVT more often have history ofprevious similar episodes .(cutoff of 3 years)


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SVT vs VT

Physical examination -Overall appearance of patient is not critical.

-The widespread impression that hemodynamic stability

indicates SVT is wrong and can lead to dangerous mistreatment.

-Physical findings that indicate presence of AV dissociation (variable-intensity S1,variation in BP unrelated to respiration) ifpresent are useful.

-Termination of WCT by maneuvers like Valsalva, carotid sinuspressure, or adenosine is strongly in-favor of SVT but there arewell-documented cases of VT responsive to these.

-Diagnostic injection of verapamil or beta-blockers should bediscouraged. (prolonged hypotension).


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What is WCT?It is refers to dysrhythmias with

rate greater than 100

beats/min associated with QRScomplex duration of more than0.12 sec

It is divided to:

=Regular

=Irregular


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Causes of WCT:

Irregular WCT:

Afib with BBB or IVCD (pre-existent or rate related)an example Asherman phenomenon

Afib with anterograde conduction over accessorypathway in WPW

Polymorphic VT ex: Torsades de pointes or due toDigitalis intoxication

Other causes of an irregular rhythm (A flutter withvariable conduction, ) with BBB, WPW, IVCD


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Causes of WCT:

Regular rhythm:

Ventricular driven rhythm:

VT : worst case scenario

Supraventricular rhythm with aberrant conduction:

SVT with BBB

SVT with accessory pathway Ex: WPW


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VT SVT withaberrancy

History Age>50Hx of MI, CHD, CABG, ASHD

Mitral valve prolapse

Previous Hx of VT

Mitral valve prolapse,s (WPW)

Previous Hx of SVT

Physicalexamination

Cannon A wave

Variation in arterial pulse

Variation in S1

Absence of variability

ECG Fusion beatsAV dissociation

QRS >0.14

Extreme LADNo response to vagal

maneuvers

Preceding P waves with QRS

QRS


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3 Most well accepted Criteria for WCT

Wellens criteria

Kindwalls criteria for VT in LBBB

Brugadas 4-step approach


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Wellens criteria

VT favored in the presence of

AV Dissociation

Left Axis Deviation Capture or Fusion Beats

QRS generally greater than 140 msec

Precordial QRS concordance

RSR in V1, mono- or biphasic QRS in V1, ormonophasic QS in V6


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Kindwalls ECG criteria for VT inLBBB.

R wave in V1 or V2 of >30 ms duration

Any Q wave in V6 Duration of >60 ms from the onset of the QRS

to the nadir of the S wave in V1 or V2

Notching on the downstroke of the S wave in

V1 or V2


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Brugada criteriaTable I.

Diagnosis Of Wide QRS Complex Tachycardia With A Regular Rhythm

Step 1. Is there absence of an RS complex in all precordial leads V1 V6?

If yes, then the rhythm is VT.

Sens 0.21 Spec 1.0Step 2. Is the interval from the onset of the R wave to the nadir of the S

wave greater than 100 msec in any precordial leads?


Sens 0.66 Spec 0.98Step 3. Is there AV dissociation?


Sens 0.82 Spec 0.98Step 4. Are morphology criteria for VT present? See Table II.


Sens 0.99 Spec 0.97


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Morphology Criteria for VT


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R-wave to Peak Time 50ms in lead II strongly suggests VT

In 2010 Joseph Brugada published a new criterion to differentiate VT

from SVT in wide complex tachycardias.

Ultrasimple Brugada criterion
http://en.ecgpedia.org/wiki/File:RWPT.svg


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Arrythmias in pre excitation orWPW syndrome

Regular mostly AVRT

Wide complex tachycardia

Irregularatrial arrythmias


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Management of WCT If the patient is hemodynamically unstable,

the first-choice therapy for ventriculartachycardia (VT) is synchronized direct-current (DC) cardioversion with 50 100 J

If the patient has a preserved heart function,the first-line treatment is lidocaine.

Alternatives include either amiodarone orprocainamide.
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If the patient has polymorphic VT with anormal baseline QT interval, AHA guidelinesstate that the first steps are to treat ischemia

and correct any electrolyte imbalance. If cardiac function is impaired, use

amiodaroneorlidocaine,followed bysynchronized DC cardioversion


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If the patient has polymorphic VT with aprolonged baseline QT interval, ACLS

guidelines state that any electrolyteimbalance should be corrected. Followingthis, any one of these treatments can beadministered: magnesium sulfate, overdrive

pacing, or lidocaine
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Long-term treatment of sustained ventriculararrhythmias includes placement of an

implantable cardioverter-defibrillator (ICD)and possible adjunctive therapy withamiodarone or sotalol. Patients should beunder the care of a cardiologist or

electrophysiologist
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Thank you

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