Wide complex tachycardia differential diagnosis

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

Differential Diagnosis

Algorithms to Distinguish VT from SVT

Brugada Criteria

Absence of an RS complex in all precordial leads?

yes

VT SN=0.21 SP=1.0

no

R to S interval>100ms 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 V1-2 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. In addition to 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 (v(i)) and the terminal 40 ms (v(t)) of the same QRS complex is used to estimate the (v(i)) and terminal (v(t)) ventricular activation velocity ratio (v(i)/v(t)). A v(i)/v(t) > 1 suggests SVT and a v(i)/v(t) ≤ 1 suggests VT.

The method calculating Vi/Vt is shown below. Because the Vi/Vt is < 1, a diagnosis of VT is suggested by the tracing:

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ACC Algorithm for Distinguishing SVT from VT

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

ACC algorithm

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