Wide complex tachycardia differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Rim Halaby

Overview

When wide QRS tachycardia is present on ECG, it is necessary to differentiate whether it is caused by ventricular tachycardia (VT) or supraventricular tachycardia (SVT). In addition to signs on ECG, the clinical history and the age of the patient provide some clues to the nature of the wide QRS tachycardia. While older patients with prior history or myocardial infarction most likely have VT, young hemodynamically stable patients presenting for paroxysmal tachycardias most likely have SVT. Nevertheless, the main differentiating means between VT and SVT relies primarily on ECG findings for which several algorithms have been developed. Examples of algorithms include Brugada criteria and Vereckei algorithm.[1]

Differential Diagnosis

Differentiating VT from SVT

Several ECG criteria and algorithms have been used to differentiate VT and SVT, the common one of which is Brugada algorithm. Below is a list of all algorithms:

  • Brugada algorithm: sensitivity 89%, specificity 59.2%[2]
  • The lead II R-wave-peak-time: sensitivity 60%, specificity 82.7%[3]
  • The aVR algorithm: sensitivity 87.1%, specificity 48%[4]
  • The Bayesian algorithm: sensitivity 89%, specificity 52%[5]
  • The Griffith algorithm: sensitivity 94.2%, specificity 39.8%[6]

Brugada Criteria

 
 
 
 
 
Absence of an RS complex
in all precordial leads?
 
 
 
 
 
Yes?

VT (SN=0.21 SP=1.0)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
R to S interval>100 ms in
one precordial lead?
 
 
 
 
 
Yes?

VT (SN=0.21 SP=1.0)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
AV dissociation?
 
 
 
 
 
Yes?

VT (SN=0.82 SP=0.98)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Morphology criteria for VT present
both in precordial leads V1, V2 and V6?
 
 
 
 
 
Yes?

VT (SN=0.987 SP=0.965)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
SVT (SN=0.965 SP=0.987)
 
 
 
 
 
 
 
 
 
 
 
 

Vereckei Criteria

  • An algorithm has been proposed by Vereckei and colleagues, wherein in addition to do the traditional criteria, the voltage change on the EKG is used as a final discriminatory criteria.
  • In this method, the voltage change during the initial 40 ms (Vi) and the terminal 40 ms (Vt) of the same QRS complex is used to estimate the (Vi) and terminal (Vt) ventricular activation velocity ratio (Vi/Vt).
  • A Vi/Vt > 1 suggests SVT and a Vi/Vt ≤ 1 suggests VT.[4]


 
 
 
 
 
AV dissociation present?
 
 
 
 
 
Yes?

VT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initial R wave in aVR present?
 
 
 
 
 
Yes?

VT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
QRS morphology unlike BBB or FB
 
 
 
 
 
Yes?

VT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Vi/Vt≤1?
 
 
 
 
 
Yes?

VT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
SVT
 
 
 
 
 
 
 
 
 
 
 
 
Calculation of Vi/Vt

Shown below is an image demonstrating the method used to calculate Vi/Vt. In this tracing, Vi/Vt is < 1 is suggestive of ventricular tachycardia according to Vereckei criteria.


ACC Algorithm

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Wide QRS complex tachycardia
(QRS duration greater than 120 ms)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Regular or irregular?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Regular
 
 
 
 
 
 
 
 
 
 
 
Irregular
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is QRS identical to that during SR?
If yes, consider:
- SVT and BBB
- Antidromic AVRT
 
 
 
 
 
 
 
 
Atrial fibrillation
Atrial flutter / AT with variable
conduction and:
a) BBB or
b) Antegrade conduction via AP
 
 
 
 
 
 
 
 
Vagal maneuvers or
adenosine
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Previous myocardial infarction or structural heart disease? If yes, VT is likely.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1 to 1 AV relationship?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes or unknown
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
V rate faster than A rate
 
A rate faster than V rate
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
QRS morphology in precordial leads
 
 
 
 
 
 
 
 
 
VT
 
Atrial tachycardia
Atrial flutter
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Typical RBBB
or LBBB
 
Precordial leads:
- Concordant
- No R/S pattern
- Onset of R to nadir longer than 100ms
 
RBBB pattern:
- qR, Rs or Rr' in V1
- Frontal plane axis range
from +90 degrees to -90 degrees
 
LBBB pattern:
- R in V1 longer than 30 ms
- R to nadir of S in V1 greater than 60 ms
- qR or qS in V6
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
SVT
 
VT
 
VT
 
VT
 
 
 
 
 
 
 
 
 
 


The above algorithm is adapted from the American College of Cardiology.

References

  1. http://en.ecgpedia.org/wiki/Approach_to_the_Wide_Complex_Tachycardia
  2. Brugada P, Brugada J, Mont L, Smeets J, Andries EW (1991). "A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex". Circulation. 83 (5): 1649–59. PMID 2022022.
  3. Pava LF, Perafán P, Badiel M, Arango JJ, Mont L, Morillo CA; et al. (2010). "R-wave peak time at DII: a new criterion for differentiating between wide complex QRS tachycardias". Heart Rhythm. 7 (7): 922–6. doi:10.1016/j.hrthm.2010.03.001. PMID 20215043.
  4. 4.0 4.1 Vereckei A, Duray G, Szénási G, Altemose GT, Miller JM (2007). "Application of a new algorithm in the differential diagnosis of wide QRS complex tachycardia". Eur Heart J. 28 (5): 589–600. doi:10.1093/eurheartj/ehl473. PMID 17272358.
  5. Lau EW, Pathamanathan RK, Ng GA, Cooper J, Skehan JD, Griffith MJ (2000). "The Bayesian approach improves the electrocardiographic diagnosis of broad complex tachycardia". Pacing Clin Electrophysiol. 23 (10 Pt 1): 1519–26. PMID 11060873.
  6. Griffith MJ, Garratt CJ, Mounsey P, Camm AJ (1994). "Ventricular tachycardia as default diagnosis in broad complex tachycardia". Lancet. 343 (8894): 386–8. PMID 7905552.

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