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
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