Ventricular tachycardia electrocardiogram

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in Chief: Sara Zand, M.D.[2] Avirup Guha, M.B.B.S.[3]; Priyamvada Singh, M.D. [4]

Overview

Finding on ECG associated with VT include: AV dissociation, atypical right bundle branch block or left bundle branch block characteristics, QRS> 140 ms for wide complex tachycardia with right bundle branch block pattern and QRS > 160 ms for wide complex tachycardia with left bundle branch block pattern, concordance or same polarity in all precordioal leads, rightward superior QRS axis.

Electrocardiogram

Common ECG criteria associated with VT include:[1]

  • Chest Lead Concordance
  • QRS complexes in all 6 precordial leads (V1–V6) uniformly shown a monophasic pattern with same polarity ( R for positive concordance and QS for negative concordance)
  • Wide complex tachycardias with positive concordance demonstrating VT originating from the posterobasal left ventricle.
  • Wide complex tachycardias with negative concordance may arise from VT originating for the anteroapical left ventricle
  • Absence of concordance does not rule out VT diagnosis.
  • Differences in Ventricular Activation Velocity
  • slurred initial components of the QRS complex due to slower cardiomyocyte‐to‐cardiomyocyte conduction ( R wave peak time in lead II ≥50 ms, or RS interval ≥100 ms in any of the precordial leads [V1–V6])
  • Rapid propagates from conduction system and activation the remainder of the myocardium
  • Rapid or sharper deflections in the terminal portion of QRS complex ( the ratio of the voltage excursion during the initial [Vi] and terminal [Vt] 40 ms of the QRS complex <1)
  • Comparison to the baseline ECG



 
 
 
 
 
 
 
 
 
 
 
 
 
Limb leads algorithm
  • Monophasic R wave in avR
  • Negative QRS in 2,3, avF
  • Opposing QRS in limb leads
 
 
 
 
 
 
 
 
 
 
 
RWPT algorithm
  • R wave peak time ≥50 ms in lead 2
 
 
 
 
 
 
 
 
The VT score
  • Initial R wave in V1 (+1)
  • Initial r wave>40 ms in V1-V2 (+1)
  • Notched S in V1 (+1)
  • Initial R in avR (+1)
  • RWPT≥50ms in lead 2 (+1)
  • NO RS inV1-V6 (+1)
  • AV dissiciation(+2)
  • ≥3, 99.6% specific for VT
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    Brugada algorithm
    • NO RS in V1-V6
    • RS interval>100 ms in one precordial lead
    • AV dissociation
    • VT morphology criteria in V1,V2,V6
     
     
     
     
     
    Ventricular tachycardia algorithm
     
     
     
     
     
    Vereckie avR algorithm
  • Initial dominant R wave
  • Initial r or q wave>40 ms
  • Notched downstroke of negative QRS
  • Vi<Vt
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    Pachon scoring algorithm
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     





    EKG Examples

    Shown below is an EKG with a rapid ventricular rate of nearly 190 beats per minute with wide QRS complex in all leads depicting ventricular tachycardia.

    Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page


    Shown below is an EKG with a rapid ventricular rate of nearly 150 beats per minute with wide QRS complex in all leads depicting ventricular tachycardia.

    Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page


    Shown below is an EKG with a rapid ventricular rate of nearly 250 beats per minute with wide QRS complexes in all leads depicting ventricular tachycardia.

    Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page


    Shown below is an EKG with a rapid ventricular rate of nearly 215 beats per minute with wide QRS complexes in all leads depicting ventricular tachycardia.

    Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page


    Shown below is an EKG with a rapid ventricular rate of nearly 140 bpm with a left bundle branch block pattern and left heart axis.

    Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page


    Shown below is an EKG depicting ventricular tachycardia with a rate of 250 bpm, and a right bundle branch block pattern with a right heart axis.

    Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page


    Shown below is an EKG depicting ventricular tachycardia with a rate of 150 bpm, and a right bundle branch block pattern with right heart axis. The 5th and 6th complexes from the right side are fusion complexes. Furthermore this EKG shows baseline drift, which is a technical artefact

    Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/Main_Page


    Shown below is an EKG depicting a nonsustained VT of five beats duration.

    Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/File:De-Nsvt.png


    Shown below is an EKG depicting ventricular tachycardia at a rate of 145 beats per minute with a right bundle branch block pattern and left heart axis.

    Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/File:De-12lead_vt4.jpg


    Shown below is an EKG depicting biphasic ventricular tachycardia in a patient with long QT syndrome.

    Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/File:De-DVA2161.jpg


    Shown below is an EKG in a person with idiopathic ventricular tachycardia (Belhassen VT).

    Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/File:De-ECG000006.jpg


    Shown below is an EKG with a rapid ventricular rate of about 170/min with wide QRS complexes in lead II depicting ventricular tachycardia.

    Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page


    Shown below is an EKG depicting a wide complex tachycardia with a left bundle branch morphology at a rate of about 160/min. The R wave in lead V2 is broad, and the time from the beginning of the QRS in lead V2 to the peak of the S wave is longer than 80 ms. No P wave activity is clearly seen. This EKG suggests ventricular tachycardia.

    Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/File:E334.jpg



    Shown below is an EKG with a rapid ventricular rate of nearly 190 beats per minute with wide QRS complexes depicting ventricular tachycardia.

    Copyleft image obtained courtesy of ECGpedia,http://en.ecgpedia.org/wiki/File:E253.jpg



    Shown below is an EKG with a rapid ventricular rate of about 190/min with wide QRS complex in all leads depicting ventricular tachycardia.

    Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page

    For more EKG examples of ventricular tachycardia, click here.


    References

    1. Kashou, Anthony H.; Noseworthy, Peter A.; DeSimone, Christopher V.; Deshmukh, Abhishek J.; Asirvatham, Samuel J.; May, Adam M. (2020). "Wide Complex Tachycardia Differentiation: A Reappraisal of the State‐of‐the‐Art". Journal of the American Heart Association. 9 (11). doi:10.1161/JAHA.120.016598. ISSN 2047-9980.

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