APPROACH TO WIDE QRS COMPLEX TACHYCARDIA Dr HA TUAN KHANH Dr DAVID TRAN

Content Definition Causes of WCT Diagnosis criteria Clinical history Physical examination ECG criteria: Brugada criteria, other criteria, findings favoring SVT, VT vs AVRT criteria Management Unstable hemodynamic Stable hemodynamic

Stewart RB. Ann Intern Med 1986 Definition Wide QRS complex tachycardia is a rhythm with a rate of more than 100 b/m and QRS duration of more than 120 ms SVT (20%) VT (80%) Stewart RB. Ann Intern Med 1986

Causes of wide QRS complex tachycardia Supraventricular tachycardia - with prexsisting BBB - with BBB due to heart rate (aberrant conduction) - antidromic tachycardia in WPW syndrome Ventricular tachycardia

SVT vs VT Clinical history Age - ≥ 35 ys → VT (positive predictive value of 85%) Underlying heart disease Previous MI → 98% VT Pacemakers or ICD Increased risk of ventricular tachyarrhythmia Medication Drug-induced tachycardia → Torsade de pointes Diuretics Digoxin-induced arrhythmia → [digoxin] ≥2ng/l or normal if hypokalemia

SVT vs VT Physical examination Physical findings that indicate presence of AV dissociation (cannon A waves, variable-intensity S1,variation in BP unrelated to respiration) if present are useful Termination of WCT in response to maneuvers like Valsalva, carotid sinus pressure, or adenosine is strongly in-favor of SVT but there are well-documented cases of VT responsive to these

SVT vs VT ECG criteria: Brugada algorithm Brugada P. Ciculation 1991

Step 1

Step 2

Step 3

Step 4: LBBB - type wide QRS complex SVT VT R wave >40ms small R wave notching of S wave V1 fast downslope of S wave > 70ms V6 Q wave no Q wave

Step 4: RBBB - type wide QRS complex SVT VT rSR’ configuration monophasic R wave qR (or Rs) complex V1 or R/S > 1 R/S ratio < 1 QS complex V6 or

Step 4: RBBB morphology

Step 4: LBBB morphology

Other ECG criteria North - west QRS axis deviation Negative or positive concordance Fusion beats, capture beats Ventriculoatrial conduction with block RBBB morphology with LAD > - 300 LBBB morphology with RAD > + 900 Previous ECG show MI or previous ECG show that during sinus rhythm, bifascular block is present, which changes in configuration during tachycardia

Concordance and Northwest Axis

Fusion beat and capture beat

Ventriculoatrial conduction with block

RBBB morphology with LAD

LBBB morphology with RAD

Previous MI

Previous LBBB

Findings favoring SVT Triphasic pattern in V1 and V6 Rabbit’s ear Previous ECG: Preexistent BBB or preexcitation

Triphasic pattern

Rabbit’s ear

Wide complex SVT from preexisting RBBB

Wide complex SVT from preexisting LBBB

VT vs AVRT ECG criteria Brugada P. Ciculation 1991

Wide complex SVT from bypass tract

Summary : diagnosis evaluation ACC/AHA/ESC guidelines for management of pt with SVT. Circulation 2003

Management – Hemodynamic compromise Unstable patient, but still responsible with a discernible BP and/or pulse: - Emergent synchronized cardioversion - If the QRS complex and T wave cannot be distinguished accurately → immediate defibrillation Unstable patient, unresponsive or pulseless → standard ACLS resusciation algorithms

ACLS pulseless arrest algorithm AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Ciurculation 2005

Management – Stable hemodynamic VT or WCT of uncertain etiology: Any associated conditions (cardiac ischemia, heart failure, electrolyte abnormalities or drug toxicities) Class I and III antiarrhythmic drugs - Amiodarone: 150mg IV/10mins followed by an infusion of 1mg/min for 6 hours, then 0,5mg/min - Procainamide: 15-18mg/kg infusion over 25-30mins, followed by 1-4mg/min by continuous infusion - Lidocaine: 1-1,5mg/kg IV/2-3mins followed by an infusion of 1-4mg/min Urgent or elective cardioversion

Management – Stable hemodynamic SVT Vagal maneuvers: carotid sinus pressure (if no carotid bruits) or Valsava maneuver Adenosine: 6mg over 1-2 seconds. If the initial dose is ineffective, a 12mg dose may be given and repeated once if necessary Calcium channel blocker (Verapamil 2.5 to 5mg IV) or beta blokers (Metoprolol 5 to 10 mg IV) Cardioversion

Acute management hemodynamically stable and regular tachycardia ACC/AHA/ESC guidelines for management of pt with SVT. Circulation 2003

ACC/AHA/ESC guidelines for management of pt with SVT. Circulation 2003 Recommendation acute management hemodynamically stable and regular tachycardia ACC/AHA/ESC guidelines for management of pt with SVT. Circulation 2003

Tachycardia algorithm AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Ciurculation 2005

Tachycardia algorithm

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