Ventricular tachycardia electrocardiogram: Difference between revisions

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{{Ventricular tachycardia}}
{{Ventricular tachycardia}}
{{CMG}}; '''Associate Editor-in Chief''': [[User:Avirupguha|Avirup Guha, M.B.B.S.]][mailto:avirup.guha@gmail.com]; [[Priyamvada Singh|Priyamvada Singh, M.D.]] [mailto:psingh@perfuse.org]
{{CMG}}; '''Associate Editor-in Chief''': {{Sara.Zand}} [[User:Avirupguha|Avirup Guha, M.B.B.S.]][mailto:avirup.guha@gmail.com]; [[Priyamvada Singh|Priyamvada Singh, M.D.]] [mailto:psingh13579@gmail.com]


==Overview==
==Overview==
The diagnosis of [[Ventricular tachycardia]] almost completely depends on EKG findings. The details are illustrated below. It is important to differentiate it from other wide complex tachycardias.
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.
==Ventricular Tachycardia==
* Ventricular tachycardia originates from a ventricular focus
* Lasts more than 30 seconds
* Broad [[EKG|QRS]] complexes: rate of >90 beats/minute
== Paroxysmal Ventricular Tachycardia ==
# Rapid succession of three or more ectopic beats.
# Sustained if it lasts longer than 30 seconds.
# Called incessant if the tachycardia is recurrent and the episodes are interrupted by only a few sinus beats.


=== EKG Findings ===
==[[Electrocardiogram]]==
# Abnormal and wide QRS complexes with secondary [[ST segment]] and [[T wave]] changes. <br>
Common [[ECG]] criteria associated with [[VT]] include:<ref name="KashouNoseworthy2020">{{cite journal|last1=Kashou|first1=Anthony H.|last2=Noseworthy|first2=Peter A.|last3=DeSimone|first3=Christopher V.|last4=Deshmukh|first4=Abhishek J.|last5=Asirvatham|first5=Samuel J.|last6=May|first6=Adam M.|title=Wide Complex Tachycardia Differentiation: A Reappraisal of the State‐of‐the‐Art|journal=Journal of the American Heart Association|volume=9|issue=11|year=2020|issn=2047-9980|doi=10.1161/JAHA.120.016598}}</ref>
#* Usual QRS duration is > 0.12 seconds, may be shorter if the ectopic focus is located in the ventricular septum.
#* The secondary [[ST segment]] and [[T wave]] changes are in a direction that is opposite the major deflection of the [[QRS]].
#* A ventricular rate between 140 and 200 BPM.
#* When the rate is >200 and has a sine wave appearance, it is called [[ventricular flutter]].
#* When the rate is <110 BPM it is called non-paroxysmal VT.
# A regular or slightly irregular (up to 0.03 seconds) rhythm. <br>
# Abrupt onset and termination. <br>
# AV dissociation. <br>
#* Atrial rate slower than ventricular rate.
#* No relationship between atrial activity and ventricular activity.
#* There can be VA conduction.
#*:# The RP interval is >0.11 seconds.
#*:# Occurs in about 50% of cases.
#*:# Uncommon when the ventricular rate is rapid (only 1/7 when the rate was>200).
# Capture beats. <br>
#* Occurs when a supraventricular impulse is conducted and captures the ventricle.
#* They are rare.
# Fusion beats. <br>
#* Rare in VT at a rapid rate.<ref>Chou's Electrocardiography in Clinical Practice Third Edition, pp. 398-409.</ref> <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:194 ISBN 1591032016</ref> <ref>Hammill S. C. Electrocardiographic diagnoses: Criteria and definitions of abnormalities, Chapter 18, MAYO Clinic, Concise Textbook of Cardiology, 3rd edition, 2007 ISBN 0-8493-9057-5</ref>


*'''[[Atrioventricular dissociation]]'''
::*The key diagnostic criterion for [[VT]] especially when the  [[ventricular]] rate exceeds the [[atrial]] rate
::*The absence of AV dissociation  does not rule out [[VT]]
::*The series of [[QRS]] complexes uncoupled from dissociated [[P waves]]
::* Limiting the [[atrial]] [[rhythm ]] by self‐governing [[ventricular ]] [[rhythm]]
::* [[Capture beat]] or single [[QRS]] complex resembling the [[patient]]'s baseline [[rhythm]] due to stopping  [[ventricular]] depolarization by [[supraventricular]] impulse
::* [[Fusion beat]] or a hybrid [[QRS]] complex resembling the [[ventricular depolarization]] characteristics of the [[VT]] and baseline [[rhythm]]
*If [[ventricular]] impulses conduct retrograde through the [[His‐Purkinje]] system to depolarize the [[atria]], [[VT]] will not exhibit [[atrioventricular dissociation]].
*'''[[Morphologic criteria]]'''
::* [[VT]] is the most likely diagnosis if a wide [[QRS]] tachycardia demonstrates a [[QRS]] patten incompatible with typical right or [[left bundle branch block]] characteristics.
::* In the presence of wide [[QRS]] tachycardia with atypical [[right bundle block]] characteristics including monophasic R wave in V1 or V2 and QS pattern in V6, [[VT]] is the most likely diagnosis.
::* When there is [[wide complex tachycardia]] with classic [[left bundle branch block pattern]] ( r wave onset to S wave nadir <60 ms in V1 or V2 and notched monophasic R wave in V6), [[supraventricular tachycardia]] is the most likely diagnosis.
*'''[[QRS]] duration'''
::*[[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]] indicating [[ventricular tachycardia]].
::*[[QRS]] >160 ms may also be seen in [[supraventricular tachycardia]] especially among [[patients]] with ongoing [[antiarrhythmic]] use, [[electrolyte]] disturbances, [[conduction delays]], or severe underlying [[structural heart disease]] or [[cardiomyopathies]].
::* [[Fascicular VT]] may demonstrate substantial impulse propagation within the [[conduction system]] with [[QRS]] durations <120 ms
*'''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 tachycardia]]s with positive concordance demonstrating  [[VT]] originating from the [[posterobasal]] [[left ventricle]].
::*[[Wide complex tachycardia]]s with negative concordance may arise from [[VT]] originating for the anteroapical left ventricle
::*Absence of concordance does not rule out [[VT]] diagnosis.
*'''[[QRS]] Axis'''
::*Rightward superior [[QRS]] axis ( northwest axis) between −90° and −180°
::* Dominant R wave in lead [[avR]]
::*Coexistence of left‐ or right‐axis deviation with right or [[left bundle branch block]]
::*In the presence of  scar‐related [[VT]] mapped to the anterolateral wall of the [[left ventricle]] may show a [[wide complex tachycardia]] with an atypical [[right bundle branch block]] pattern and rightward and superior [[QRS]] axix which is uncommon in [[supraventricular tachycardia]] with [[right bundle branch block]] aberrancy.
*'''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)


==Brugada criteria==
*'''Comparison to the baseline [[ECG]]'''
* The Brugada criteria is the commonest algorithm used to diagnose [[Ventricular Tachycardia]].
::* Findings the changes in the [[QRS]] axis, [[T axis]], and [[QRS]] duration between [[wide complex tachycardia]] and baseline [[ECG]] ( an [[ECG]] taken before  or after [[tachycardia]] maybe helpful for diagnosis of [[VT]].
* In Brugada's algorithm four criteria for VT are sequentially assessed.
* If any one of the four criteria are fulfilled diagnosis of VT is made
* If none of the criteria are fulfilled a diagnosis of SVT is made.
* The four criteria are as follow:
** Check for concordance in the precordial leads. Concordance is said to be present when the QRS complexes in all the leads V1 to V6 are monophasic (all positive or all negative) with the same polarity. If any of the precordial leads has a biphasic QRS concordance is absent.
** If the longest RS interval in any lead is >100 msec and R wave is wider than S wave a diagnosis of VT can be made.
** If longest RS interval is less than 100 msec, presence of AV dissociation can lead to a diagnosis of VT.
** If longest RS interval is less than 100 msec, and AV dissociation is not present then the QRS morphology is used to make the diagnosis. QRS morphology criteria consistent with VT must be present in leads V1 or V2 and in lead V6. A VT with RBBB morphology is here when the QRS polarity in lead V1 and V2 are poisitive whereas, a LBBB pattern occurs with a negative QRS polarity. If either the V1-V2 or the V6 criteria are not consistent with VT, an diagnosis of SVT is made.


==Electrocardiographic diagnostic findings==


[[Image:Lead II rhythm ventricular tachycardia Vtach VT.jpg|500 px|center|thumb|Ventricular tachycardia in Lead II (rhythm)]]


# Abnormal and wide QRS complexes with secondary [[ST segment]] and [[T wave]] changes. <br>
#* Usual QRS duration is > 0.12 seconds, may be shorter if the ectopic focus is located in the ventricular septum.
#* The secondary [[ST segment]] and [[T wave]] changes are in a direction that is opposite the major deflection of the [[QRS]].
#* A ventricular rate between 140 and 200 BPM.
#* When the rate is >200 and has a sine wave appearance, it is called [[ventricular flutter]].
#* When the rate is <110 BPM it is called non-paroxysmal VT.
# A regular or slightly irregular (up to 0.03 seconds) rhythm. <br>
# Abrupt onset and termination. <br>
# AV dissociation. <br>
#* Atrial rate slower than ventricular rate.
#* No relationship between atrial activity and ventricular activity.
#* There can be VA conduction.
#*:# The RP interval is >0.11 seconds.
#*:# Occurs in about 50% of cases.
#*:# Uncommon when the ventricular rate is rapid (only 1/7 when the rate was>200).
# Axis
#* Northwest quadrant is almost always VT in adults.
#* In someone with a normal QRS in sinus rhythm, a LBBB-like wide complex tachycardia with a right axis (+90 to +180) is always VT because activation in LBBB aberration always goes from right to left.
# Concordance
#* If all the precordial leads are positive (R) or negative (QS) the rhythm is very likely VT
# V1-V2 morphology
#* RBBB-morphology
#*:# RsR' or rsR' in V1 favors SVT, whereas a monophasic R, Rr', qR, or RS favors VT.
#*:# RBBB aberration the initial forces of the QRS are the same as in the narrow complex sinus rhythm.
#* LBBB-morphology
#*:# V1 and V2 require analysis because the initial forces in V1 are often isoelectric.
#*:# R wave in V1 or V2 ≥40 msec favors VT.
#*:# The time from the onset of the QRS to the nadir of the S wave in V1 or V2 is ≥70 msec, VT is likely in the absence of Na channel blocking agents.
# V6 morphology
#* RBBB-morphology - QS or rS favors VT. Although this can be influenced by axis (it is almost always seen in VT with left axis deviation, but is seen in only approximately 50% of VT with a normal axis, even in the same patient).
#* LBBB-morphology - a qR or QS is highly predictive of VT
# Capture beats. <br>
#* Occurs when a supraventricular impulse is conducted and captures the ventricle.
#* They are rare.
# Fusion beats. <br>
#* Rare in VT at a rapid rate.<ref>Chou's Electrocardiography in Clinical Practice Third Edition, pp. 398-409.</ref> <ref>Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:194 ISBN 1591032016</ref> <ref>Hammill S. C. Electrocardiographic diagnoses: Criteria and definitions of abnormalities, Chapter 18, MAYO Clinic, Concise Textbook of Cardiology, 3rd edition, 2007 ISBN 0-8493-9057-5</ref>


====Examples of Ventricular Tachycardia:====
<div align="left">
<gallery heights="400" widths="400">
Image:Ganseman.VT1.jpg|12 lead EKG: Ventricular tachycardia.
Image:Ganseman.VT2.jpg|12 lead EKG: Ventricular tachycardia. <small> [http://www.ganseman.com/ecgbibnl.htm#_top000 Image courtesy of Dr Jose Ganseman]</small>
</gallery>
</div>


<div align="left">
{{familytree/start |summary=Sample 8}}{{familytree/start |summary=PE diagnosis Algorithm.}}
<gallery heights="400" widths="400">
{{familytree/start}}
Image:Ganseman.VT3.jpg|12 lead EKG: Ventricular tachycardia. <small> [http://www.ganseman.com/ecgbibnl.htm#_top000 Image courtesy of Dr Jose Ganseman]</small>
{{familytree | | | | | | | | | | | | | | A01 | | |A01='''Limb leads algorithm'''
Image:Ganseman.VT4.jpg|12 lead EKG: Ventricular tachycardia. <small> [http://www.ganseman.com/ecgbibnl.htm#_top000 Image courtesy of Dr Jose Ganseman]</small>
*Monophasic R wave in avR
</gallery>
*Negative [[QRS]] in 2,3, avF
</div>
*Opposing [[QRS]] in limb leads}}
{{familytree | | | | | | | | | | B01 |-|.|!|,|-| B02 | | | | | | | |B01='''RWPT algorithm'''
* R wave peak time ≥50 ms in lead 2|B02= '''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]]  }}
{{familytree | | | | | | C01 |-|-|-|-|-| C02 |-|-|-|-|-| C03 | | | |C01='''[[Brugada]] algorithm
*NO RS in V1-V6
*RS interval>100 ms in one precordial lead
*[[AV dissociation]]
*[[VT]] morphology criteria in V1,V2,V6|C02=''[[Ventricular tachycardia]] algorithm''|C03='''[[Vereckie avR]] algorithm'''
*Initial dominant R wave
*Initial r or q wave>40 ms
*Notched downstroke of negative [[QRS]]
*Vi<Vt}}
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | E01 | | | | | | | | | | | |E01='''Pachon scoring algorithm'''
* [[Wide complex tachycardia]] [[QRS]] morphology the same in baseline [[ECG]] (−1)
*Abnormal Q wave in baseline [[ECG]] (+1)
*[[AV dissociation]] (+1)
*Q wave or initial q in V6 with [[LBBB]] morphology (+1)
*Sudden normalization and morphology changes with [[AF]] in baseline [[ECG]](+1)
*[[Wide complex tachycardia]] with complete or high grade AV block (+1)
*Contralateral bundle branch block morpholy compared with baseline [[ECG]](+1)
*:score≥ 1 suggestive of [[VT]]
*:score (−1) suggestive of [[supraventricular tachycardia]]}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree/end}}


<div align="left">
<gallery heights="400" widths="400">
Image:Ganseman.VT5.jpg|12 lead EKG: Ventricular tachycardia. <small> [http://www.ganseman.com/ecgbibnl.htm#_top000 Image courtesy of Dr Jose Ganseman]</small>
Image:Ganseman.VT6.jpg|12 lead EKG: Ventricular tachycardia. <small> [http://www.ganseman.com/ecgbibnl.htm#_top000 Image courtesy of Dr Jose Ganseman]</small>
</gallery>
</div>


<div align="left">
<gallery heights="400" widths="400">
Image:12lead_vt1.jpg|Ventricular tachycardia of 140 bpm with a [[LBBB|left bundle branch block]] pattern and left heart axis.
Image:12lead_vt2.png|Ventricular tachycardia of 250 bpm with a [[RBBB|right bundle branch block]] pattern and right heart axis.
</gallery>
</div>


<div align="left">
 
<gallery heights="400" widths="400">
 
Image:12lead_vt3.png|Ventricular tachycardia of 150 bpm with a [[RBBB|right bundle branch block]] pattern and right heart axis. Note the 5th and 6th complex from the right side. These are fusion complexes.
 
Image:ventricular_flutter_12lead.jpg|Ventricular flutter on a 12 lead ECG
 
</gallery>
 
</div>
===[[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.
 
[[Image:Ganseman.VT1.jpg|center|800px]]
 
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]].
 
[[Image:Ganseman.VT2.jpg|center|800px]]
 
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 complex]]es in all leads depicting [[ventricular tachycardia]].
 
[[Image:Ganseman.VT3.jpg|center|800px]]
 
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 complex]]es in all leads depicting [[ventricular tachycardia]].
 
[[Image:Ganseman.VT6.jpg|center|800px]]
 
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 [[LBBB|left bundle branch block]] pattern and left heart axis.
 
[[Image:12lead_vt1.jpg|center|800px]]
 
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]].
 
[[Image:12lead_vt2.png|center|800px]]
 
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
 
[[Image:12lead_vt3.png|center|800px]]
 
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.
 
[[Image:Ventricular Tachycardia 2.png|center|800px]]
 
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]].
 
[[Image:Ventricular Tachycardia 1.jpg|center|800px]]
 
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]].
 
[[Image:Ventricular Tachycardia 3.jpg|center|800px]]
 
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).
 
[[Image:Ventricular Tachycardia 4.jpg|center|800px]]
 
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 [[Electrocardiogram#Limb|II]]  depicting [[ventricular tachycardia]].
[[Image:Lead II rhythm ventricular tachycardia Vtach VT.jpg|500px|center]]
 
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 [[Electrocardiogram#Precordial|V2]] is broad, and the time from the beginning of the [[QRS]] in lead [[Electrocardiogram#Precordial|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.
 
[[File:Ventricular tachycardia 1.jpg|center|500px]]
 
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.
 
[[Image:Ventricular_tachycardia.jpg‎|center|800px]]
 
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]].
[[Image:Ganseman.VT5.jpg|800px|center]]
 
Copyleft image obtained courtesy of ECGpedia, http://en.ecgpedia.org/wiki/Main_Page
 
'''For more [[EKG]] examples of [[ventricular tachycardia]],  click [[Ventricular tachycardia EKG examples|here]].'''
 
----


==References==
==References==
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[[Category:Electrophysiology]]
[[Category:Cardiology]]
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[[Category: Electrophysiology]]
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Latest revision as of 04:22, 30 May 2021

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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
    •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    		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
    •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    		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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