Differential diagnosis of tachycardias
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Differential Diagnosis of Tachycardias . Differential diagnosis of broad complex tachycardias . Criteria for the diagnosis of the presence of a broad complex tachycardia: QRS >120ms = Broad Complex Tachycardia QRS <120ms = Narrow Complex Tachycardia. Narrow QRS Sinus tachycardia

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Differential Diagnosis of Tachycardias

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Differential diagnosis of tachycardias

Differential Diagnosis of Tachycardias


Differential diagnosis of tachycardias

Differential diagnosis of broad complex tachycardias

  • Criteria for the diagnosis of the presence of a broad complex tachycardia:

  • QRS >120ms = Broad Complex Tachycardia

  • QRS <120ms = Narrow Complex Tachycardia


Tachycardias

Narrow QRS

Sinus tachycardia

Atrial tachycardia

Atrial fibrillation

Atrial Flutter

AVRNT

AVRT

SVT

Broad QRS

Ventricular tachycardia

SVT with abnormal conduction

Bundle branch block

Rate related

Ventricular pre- excitation

Tachycardias


Differential diagnosis of tachycardias

Differential diagnosis of broad complex tachycardias

The rhythm strip taken from a single lead is generally insufficient to make a differential diagnosis between an SVT with aberrancy or VT. A 12 lead ECG is required for making an accurate diagnosis.


Differential diagnosis of tachycardias

Differential diagnosis of broad complex tachycardias

The presence of anyone of the following confirms the diagnosis of VT:

  • Evidence of A.V.Dissociation….in the form of independent atrial activity.

  • Presence of fusion beats

  • Presence of capture beats


Av dissociation

AV dissociation

  • Atrioventricular dissociation in monomorphic ventricular tachycardia (note P waves, arrowed)


Capture beat

Capture beat

  • Capture beat


Fusion beat

Fusion Beat

  • Fusion beat


Differential diagnosis of tachycardias

In patients with IHD…. …. 90% of broad complex tachycardias will be ventricular in origin

Differential diagnosis of broad complex tachycardias


Differential diagnosis of tachycardias

QRS Contours Favouring Ventricular Tachycardia

Wellens Gulamhusein

V1

84/86 (98%)

15/15 (100%)

V1

7/7 (100%)

177/187 (95%)

V6

27/31 (87%)

189/190(100%)

V6

17/17 (100%)

38/40(94%)

Wagner (2001) Marriotts Practical Electrocardiography 10th Ed.


Differential diagnosis of tachycardias

Differential diagnosis of broad complex tachycardias

QRS Contours Favouring Ventricular Aberration

Wellens Gulamhusein

V1

38/41 (93%)

55/55 (100%)

V6

44/47 (94%)

27/27 (100%)

Wagner (2001) Marriotts Practical Electrocardiography 10th Ed.


Differential diagnosis of tachycardias

R’

Differential diagnosis of broad complex tachycardias

Tachycardias presenting with a basically RBB pattern

SVT is more the likely diagnosis where there is a triphasic QRS…rSR’; with the R’ wave taller than the initial r.

V1

Professor A.J Camm: “A Master Class in The Differential Diagnosis of Broad Complex Tachycardias.


Differential diagnosis of tachycardias

S

Differential diagnosis of broad complex tachycardias

Tachycardias presenting with a basically RBB pattern

If the ‘S’ wave at least reaches the isoelectric line (or goes beyond it) the tachycardia is most likely to be supra- ventricular in origin.

V1

Professor A.J Camm: “A Master Class in The Differential Diagnosis of Broad Complex Tachycardias.


Differential diagnosis of tachycardias

Differential diagnosis of broad complex tachycardias

Tachycardias presenting with a basically RBB pattern

S

NB: Proviso:

If the ‘S’ wave is not much more than a notch on the down-stroke, then the tachycardia is less likely to be supraventricular in origin.

V1

Professor A.J Camm: “A Master Class in The Differential Diagnosis of Broad Complex Tachycardias.


Differential diagnosis of tachycardias

Differential diagnosis of broad complex tachycardias

Tachycardias presenting with a basically RBB pattern

R:S <1

VT

R:S >1

SVT

V6

Professor A.J Camm: “A Master Class in The Differential Diagnosis of Broad Complex Tachycardias.


Differential diagnosis of tachycardias

Differential diagnosis of broad complex tachycardias

Tachycardias presenting with a basically LBB pattern

V1

Kinwall Criteria:

The Presence of anyone of these characteristics points to the diagnosis of VT.

  • Initial ‘r’ wave in V1 > 30ms in duration.

  • Presence of a ‘notch’ on the down-stroke of the ‘S’ wave.

  • The duration of the complex from the start of the ‘r’ wave to the nadir of the ‘S’ wave = 60ms or more.


Differential diagnosis of tachycardias

Differential diagnosis of broad complex tachycardias

Tachycardias presenting with a basically LBB pattern

30ms

‘notch’

V1

60ms

Professor A.J Camm: “A Master Class in The Differential Diagnosis of Broad Complex Tachycardias.


Differential diagnosis of tachycardias

Differential diagnosis of broad complex tachycardias

Tachycardias presenting with a basically LBB pattern

‘q’

The presence of any ‘q’ wave points to the likelihood that the tachycardia is ventricular in origin.

V6

Professor A.J Camm: “A Master Class in The Differential Diagnosis of Broad Complex Tachycardias.


Differential diagnosis of tachycardias

Differential diagnosis of broad complex tachycardias

Brugarder et al Criteria:

‘rS’ patterns are usually present in one or more precordial leads therefore:

  • A no ‘rS’ pattern most likely suggests that the tachycardia is ventricular in origin.

  • If there are any ‘rS’ complexes; if the distance from the start of the ‘r’ wave to the ‘nadir’ of the ‘S’ wave is 100ms or more it indicates that the tachycardia is most likely to be ventricular in origin.


Differential diagnosis of tachycardias

Differential diagnosis of broad complex tachycardias

V1

V6

100ms

Professor A.J Camm: “A Master Class in The Differential Diagnosis of Broad Complex Tachycardias.


Differential diagnosis of tachycardias

Differential diagnosis of broad complex tachycardias

Concordance of The QRS complexes in The Precordial Leads

“When all of the ventricular complexes from leads V1 to V6 are either negative (concordant precordial negative) or positive (concordant precordial positive), the diagnosis is most likely VT, since these patterns would be atypical of either RBBB or LBBB.”

Wagner (2001) Marriotts Practical Electrocardiography 10th Ed.


Differential diagnosis of tachycardias

Differential diagnosis of broad complex tachycardias

Negative Concordance

Positive Concordance

Wagner (2001) Marriotts Practical Electrocardiography 10th Ed.


Differential diagnosis of tachycardias

Cardiac Axis:

  • If the Cardiac axis is between -1500 and -/+ 1800, this is clearly abnormal and is a useful clue to the tachycardia being ventricular in origin since the electrical axis of neither RBBB or LBBB produce such extreme axis deviation.


Differential diagnosis of tachycardias

Broad complex Tachycardia

yes

Independent p waves visible

VT

no

no

Are QRS in V1 and V6 typical for left or right BBB

VT

yes

SVT a possibilty


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