Differential diagnosis in narrow QRS complex tachycardias Hosted by DR Adrian Baranchuk MD FACC and DR Kevin Michael MBCB MPhil MD Presentation

“There is no algorithm that can cover ALL clinical scenarios”… Overview A simple and useful algorithm to differentiate narrow complex tachycardias Clinical applicability Easy to remember Real clinical cases Some less frequent presentations “There is no algorithm that can cover ALL clinical scenarios”… November-30-18 Differential diagnosis in narrow QRS complex tachycardias Presentation

Algorithm 3 Questions: Narrow vs. Wide Regular vs. Irregular Where is the P-Wave November-30-18 Differential diagnosis in narrow QRS complex tachycardias Presentation

Wide Complex Tachycardia Tachycardias SUPRAVENTRICULAR VENTRICULAR SINUS TACHYCARDIA ATRIAL FIBRILLATION ATRIAL FLUTTER ATRIAL TACHYCARDIA AVNRT AVRT MONOMORPHIC VT POLYMORPHIC VT TORSADES DES POINTES VENTRICULAR FIBRILLATION 90% Narrow Complex Tachycardia Wide Complex Tachycardia November-30-18 Differential diagnosis in narrow QRS complex tachycardias Presentation

Algorithm Narrow Complex Tachycardia Regular P before QRS Atrial Fibrillation A. Flutter w/variab.con. No P waves - P after QRS + - ST LAT AVNRT JT Saw tooth A Flutter RP<PR RP>PR AVRT Atypical AVNRT Irregular November-30-18 Differential diagnosis in narrow QRS complex tachycardias Presentation

Cardiac Tamponade CASE 1 Sinus tachycardia Electrical alternans Low qrs voltage Cardiac Tamponade CASE 1 November-30-18 Differential diagnosis in narrow QRS complex tachycardias Presentation

Low Atrial Tachycardia - P-wave inf. Leads - P-wave in lead I Activation caudo-cranial left to right Negative P-waves in inferior leads CASE 2 November-30-18 Differential diagnosis in narrow QRS complex tachycardias Presentation

Atrial Flutter CASE 3 Saw tooth Think in AFL if HR 150 bpm @ rest!!! CSM: variable conduction Atrial Flutter CASE 3 November-30-18 Differential diagnosis in narrow QRS complex tachycardias Workshop

Sinus Tachycardia CASE 4 VAGAL MANEUVERS SVT: “all or none” A Flutter: ↑ degree of block Sinus Tach: slow the rate Sinus Tachycardia CASE 4 November-30-18 Differential diagnosis in narrow QRS complex tachycardias Presentation

Typical AVNRT CASE 5 Regular, narrow complex - retrograde P-waves RP < PR RP < 80 ms Typical AVNRT CASE 5 November-30-18 Differential diagnosis in narrow QRS complex tachycardias Presentation

Orthodromic AVRT CASE 6 Regular, narrow complex - retrograde P-waves RP < PR RP < 80 ms Orthodromic AVRT CASE 6 November-30-18 Differential diagnosis in narrow QRS complex tachycardias Presentation

2:1 AVNRT CASE 7 P-wave in the middle of RR - retrograde P-waves Pseudo ‘R-waves 2:1 AVNRT (Infrequent Presentations) CASE 7 November-30-18 Differential diagnosis in narrow QRS complex tachycardias Presentation

“2 x 1” Tachycardia CASE 8 Narrow complex Slightly irregular 1 P-wave, 2 QRS “2 x 1” Tachycardia CASE 8 P QRS QRS Fast pathway Slow pathway November-30-18 Differential diagnosis in narrow QRS complex tachycardias Presentation

Narrow Complex Tachycardia Once Again… Narrow Complex Tachycardia Regular P before QRS Atrial Fibrillation A. Flutter w/variab.con. No P waves - P after QRS + - ST LAT AVNRT JT Saw tooth A Flutter RP<PR RP>PR AVRT Atypical AVNRT Irregular November-30-18 Differential diagnosis in narrow QRS complex tachycardias Presentation

www.HRMx.org www.doctorsfixinghearts.com November-30-18 Differential diagnosis in narrow QRS complex tachycardias Presentation