Ecg of the month, report by the journal of the louisiana state medical society. It may be of supraventricular or ventricular origin, and differential diagnosis between the two has important therapeutic and prognostic implications. The evaluation and treatment of wide qrscomplex tachycardia remains a challenge, and mismanagement is quite common. Note that 10% of wide complex tachycardias actually originate from the atria but the qrs complexes become wide due to. A narrow qrs complex 100 bpm indicates a supraventricular origin with ventricular activation occurring via the fastconducting hispurkinje system. During electrophysiology study, it suddenly gets narrow and fa. 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. Nov 10, 2012 arriving at the correct diagnosis in cases of wide complex tachycardia remains problematic for many clinicians.
Wide qrs complex tachycardia in an apparently healthy man. Wideqrs complex tachycardia american journal of cardiology. When during tachycardia the qrs is more narrow than during sinus rhythm a vt should be diagnosed. Initial evaluation and management of widecomplex tachycardia. Only 39 of 122 patients with ventricular tachycardia were correctly diagnosed initially. 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. Misdiagnosis in patients with aberrant or accessory pathway conduction was also common. Electrocardiogram showing a regular wide qrs tachycardia with left branch block lbbb like in morphology at 200 beats per minute bpm. Kindwall, ke, brown, j, josephson, me electrocardiographic criteria for ventricular tachycardia in wide complex leftbundle branch block morphology tachycardias. Application of a new algorithm in the differential diagnosis of wide qrs complex tachycardia.
Ann arbor, michigan case presentation a 78yearold man underwent an electrophysiologic procedure because of a 25year history of. Aug 18, 2007 a wct can occur in any individual presenting with tachycardia for any reason, such as fever or dehydation, if he or she has a preexisting wide qrs complex. This ecg shows a wide complex tachycardia which is overall irregular and has qrs complexes with differing morphology. 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. The differentiation of wide qrs complex tachycardias presents a challenging diagnostic dilemma to many physicians despite multiple published algorithms and approaches. 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.
In others, the diagnoses were supraventricular tachycardia with aberrant conduction 43 of 122 or simply a wide qrs tachycardia 40 of 122. Patients presenting with tachycardia most often complain of palpitation and dizziness, but can also report episodes of chest pain. Differential diagnosis of wide qrs complex tachycardias the. The correct analysis of the ecg tracing is an extremely useful tool to. Tachycardias are broadly categorized based upon the width of the qrs complex on the electrocardiogram ecg.
Figure 1, the presenting ecg, shows a regular ventricular rate of 240 beatsmin and monomorphic, wide qrs tachycardia with left bundlebranch block lbbb configuration, right axis deviation, and qrs width greater than 160 milliseconds ms, measured in v4. Causes of tachycardia tachyarrhythmia with wide qrs complexes qrs duration. Wide qrs complex tachycardia of uncertain origin in patients with stable wide qrs tachycardia of uncertain origin, adenosine and lidocaine previously were recommended. The correct analysis of the ecg tracing is an extremely useful tool to distinguish a supraventricular from a ventricular tachycardia.
Supraventricular tachycardia, ventricular tachycardia, wide qrs complex tachycardia. Wide qrs complex tachycardia is defined as a heart rate of 100 bpm and qrs duration of 120 ms. The p waves are positive in lead ii before each qrs complex, and the. A new approach to the differential diagnosis of a regular tachycardia with a wide qrs complex. Current algorithms for the diagnosis of wide qrs complex. Accahaesc guidelines for the management of patients with supraventricular arrhythmiasm executive summary a report of the american college of cardiologyamerican heart. The correct differentiation between a supraventricular and ventricular origin of a wide qrs tachycardia is of obvious diagnostic, therapeutic, and prognostic importance. From the cardiology division, department of internal medicine, university of michigan medical center. Before giving any antiarrhythmic medication, attempts should be made to determine the origin of the tachycardia.
Simple electrocardiographic criteria for rapid identi. Tachyarrhythmias in the icu acnppa critical care boot camp vanderbilt university medical center september 21, 2015 ariel kappa rn, msn, acnpbc. Simple electrocardiographic criteria for rapid identification. A wide qrs complex on tachycardia on electrocardiogram is defined as rhythm with qrs duration. Several algorithms have been developed to aid in this differentiation below. 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. Apr 09, 2012 figure 1, the presenting ecg, shows a regular ventricular rate of 240 beatsmin and monomorphic, wide qrs tachycardia with left bundlebranch block lbbb configuration, right axis deviation, and qrs width greater than 160 milliseconds ms, measured in v4. The right diagnosis has important clinical implications. Consider adenosine only if regular and monomorphic.
Tachyarrhythmias in the icu vanderbilt university medical. Wide complex tachycardia is defined as a cardiac rhythm with a rate greater than 100 beatsmin bpm and a qrs complex duration greater. Ecg shows a wideqrs complex tachycardia at a rate of 167 bpm. Wide qrs complex tachycardia can be originated by 3 main mechanisms1.
A narrow qrs complex tachycardia qrs duration 100 bpm indicates a supraventricular origin with ventricular activation occurring via the fastconducting hispurkinje system. Arriving at the correct diagnosis in cases of wide complex tachycardia remains problematic for many clinicians. A widecomplex tachycardia is a fast 100 beatsmin rhythm in which the qrs duration is greater than 120 milliseconds. As shown in fig 11, a very wide qrs is present during sinus rhythm because of sequential activation of first the right and then the left ventricle. New algorithm using only lead avr for differential. Wide qrs complex tachycardia can be originated by 3 main mechanisms 1. Wide qrs tachycardias internal medicine cardiology. The acute management of a regular narrow qrs complex tachycardia will depend on the hemodynamic state of the patient. Of those with wide qrs complexes, a nonspecific intraventricular conduction delay was the most common in buxtons report and, based on prior data, all ventricular conduction delays are not the same.
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. The ecg in figure 1 shows a wide qrs complex tachycardia at 170 bpm. But as will be discussed here, the ecg should not only tell you how to distinguish vt from other tachycardias with a broad qrs complex, but also to suspect its. Miller5 1third department of medicine, semmelweis university, school of medicine, budapest, ku.
Tachycardia with a right bundle branch blocklike qrs lead v1 monophasic r or qr or rs favors vt triphasic rsr favors svt lead v6 r to s ratio 1 r wave larger than s wavefavors svt qs or qr favors vt monophasic r favors vt triphasic favors svt tachycardia with a left bundle branch block. Wide qrs complex tachycardia, brugada criteria, ventricular tachycardia, supraventricular tachycardia introduction wide qrs complex tachycardia wct is a common arrhythmia with important therapeutic and prognostic implications and often presents a diagnostic challenge. The differentiation of wide qrs complex tachycardias. As a result, these infants may develop neonatal bradycardia or hypoglycemia. Le contea p, mallietb n, chapeletc g, trewicka d 2017 flecainideinduced wide complex qrs tachycardia. 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. Otherwise, electrophysiological studies are the definitive diagnostic investigation. Using the acls tachycardia algorithm for managing stable tachycardia. Pdf current algorithms for the diagnosis of wide qrs. Wide qrs complex tachycardia annals of internal medicine.
When doubt exists in an emergency situation, it is safest to assume that a wide complex. 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. Arguably, this is the highestrisk population of those with a wide qrs complex. A wide complex tachycardia is a fast 100 beatsmin rhythm in which the qrs duration is greater than 120 milliseconds. 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. Health, general electrocardiogram usage electrocardiography medical history taking prednisone dosage and administration tachycardia diagnosis patient outcomes. Application of a new algorithm in the differential.
Wide complex tachycardia cardiac electrophysiology clinics. The study may be underpowered to detect differences between groups. The wide qrs tachycardia annals of internal medicine. Current algorithms for the diagnosis of wide qrs complex ncbi. The differential diagnosis of wide qrs complex tachycardia. A correct diagnosis of a wide qrs tachycardia on standard 12lead ecg can be challenging. The differential diagnosis includes vt, svt with aberrant conduction, and conduction from the atria to the ventricles via an accessory pathway wolffparkinsonwhite wpw syndrome. Supraventricular tachycardia svt with an aberrant conduction attributable to a preexisting bundlebranch block or functional bundlebranch block induced by the fast heart rate. Sep 06, 2017 this ecg shows a wide complex tachycardia which is overall irregular and has qrs complexes with differing morphology. Common types of supraventricular tachycardia and usual characteristics. Baseline sinus cycle length was 900 ms, atrialhis ah interval 80 ms, and hisventricular hv interval 100 ms. The value of electrocardiography for differential diagnosis.
Application of a new algorithm in the differential diagnosis. Wide qrs complex tachycardia the ecg in prehospital. A wide complex tachycardia may represent either vt 80% or a supraventricular rhythm with aberrant conduction 20%. New algorithm using only lead avr for differential diagnosis. Acls tachycardia algorithm for managing stable tachycardia. When confronted with a wideqrscomplex tachycardia it can be difficult to differentiate between a supraventricular tachycardia with aberrancy or ventricular tachycardia. View enhanced pdf access article on wiley online library html view download pdf for offline viewing. Only monomorphic wide qrs complex tachycardias were analyzed using the following criteria in lead avr.
But there are sections of wide complex regular monomorphic rhythm within the tracing. A wct can occur in any individual presenting with tachycardia for any reason, such as fever or dehydation, if he or she has a preexisting wide qrs complex. Accahaesc guidelines for the management of patients with. Other tachycardias that create or result in wide qrs complexes will by definition be wcts. The new limb lead algorithm qiongchen,md, jinyixu,md,carolagianni. On the diagnosis of wide qrs tachycardia springerlink. Pdf the mechanism of a wide qrs tachycardia john windle. However, if a baseline or previous ecg is available then svt with aberrancy can be diagnosed with some certainty if the qrs morphology of the wide complex tachycardia is identical to the qrs morphology when the patient was previously in sinus rhythm. Thus, the first consideration should be atrial fibrillation with wpw preexcited af, and this was my first impression. Approximately 80% of all wide qrs complex tachycardias turn out to be ventricular tachycardia vt. In a man with a wideqrs complex tachycardia, a history of an inferior left ventricular scar, atrioventricular dissociation during the tachycardia, and a qrs.
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