The presenting ecg revealed a regular wide complex tachycardia wct with a right bundle branch block rbbb and left anterior fascicular block lafb pattern with p waves after the qrs complexes in a 1. Oct 05, 2012 wide complex tachycardiadiagnostic approachalgorithms sen. If its the same then its a monomorphic widecomplex tachycardia. The bayesian approach improves the electrocardiographic diagnosis of broad complex tachycardia. We describe a case of a young man referred with a broad complex tachycardia for evaluation and ablation. Broad complex tachycardias are potentially lifethreatening. Any local ems system changes to this document must follow the nc oems protocol change policy and be approved by oems. In the case of sustained wide qrs complex tachycardia, some pharmacological and. Recognition and management in the emergency room ib ray abstract cardiac arrhythmias often present as urgent medical conditions requiring immediate care. Current algorithms for the diagnosis of wide qrs complex ncbi. The differential diagnosis of wideqrs tachycardias ecg in 10. The rhythm is regular or almost regular jun 17, 2016 broad complex tachycardias are potentially lifethreatening.
A break in the rhythm is caused by a right ventricular premature complex, followed by a. Broad qrs complex tachycardia bct still presents a diagnostic challenge when confronted with a 12lead electrocardiogram ecg. The continuation of the wide qrs complex tachycardia during spontaneous transient interruption of the atrial rhythm figure 2 excludes. When atrial fibrillation occurs with aberrant conduction and a rapid ventricular response, a totally irregular broad complex tachycardia is produced.
Apr 24, 2018 the bayesian approach improves the electrocardiographic diagnosis of broad complex tachycardia. The ecg differential diagnosis includes ventricular tachycardia vt vs. The underlying cause of wide complex tachycardia tends to be ventricular tachycardia in patients 35 years of age sensitivity of 92% and a positive predictive value of 85% for vt and supraventricular tachycardia with aberrancy in patients tachycardia. It can occur at any age, but there is an increased likelihood if the atria are diseased hypertension, pulmonary disease, previous cardiac surgery, etc. Wide complex tachycardia encompasses a range of cardiac dysrhythmias, some of which can be difficult to distinguish and may require specific treatment approaches. Does this widecomplex rhythm look the same throughout the run of the rhythm. Approach to wide qrs complex tachycardias clinical gate. Unraveling the mystery of a wide complex tachycardia sciencedirect. Diagnostic criteria of broad qrs complex tachycardia. Though, these arrhythmias are potentially fatal, they need to recognized first and treated appropriately. A broad qrs complex is either caused by the ventricular conducting system not working bundle branch block or the electrical circuit not involving the atrioventricular av node correctly. Use of avr and jastrzebski algorithms in the classification of wide. Abc of clinical electrocardiography broad complex tachycardia.
During wide complex tachycardia heart rate 100min, qrs 0. Morphology of the widecomplex tachycardia the morphology of the tachycardia also give hints concerning the origin. When confronted with a tachycardia having a broad qrs complex, it is. In 8 of 9 cases of broad complex supraventricular tachycardia svt the arrhythmia was terminated, converted into a narrow complex svt, or atrioventricular block was induced. Accahaesc guidelines for the management of patients with. Wide complex tachycardia in a healthy young man ep europace. He had moderate left ventricular dysfunction and hypotension and was cardioverted. The pharmacologic and nonpharmacologic antiarrhythmic approaches discussed may, therefore, include some accahaesc guildelines 1859.
Several arrhythmias can manifest as wcts table 211. Pdf diagnosis and treatment of widecomplex tachycardias. The electrophysiology service was subsequently consulted to assist with rhythm diagnosis and management. Mar 23, 2002 broad complex tachycardias occur by various mechanisms and may be ventricular or supraventricular in origin. Broad complex tachycardias occur by various mechanisms and may be ventricular or supraventricular in origin.
Medication given for the treatment of a supraventricular tachycardia svt may be harmful to a patient. Electrophysiological study was performed and revealed a left lateral accessory pathway with antegrade decremental conduction causing antidromic reciprocating reentrant tachycardia. Wide complex tachycardia treated with amiodarone and. Wide complex tachycardia and adenosine cardiology jama. Mar 30, 2002 the bundle branch block may predate the tachycardia, or it may be a rate related functional block, occurring when atrial impulses arrive too rapidly for a bundle branch to conduct normally. If a widecomplex tachycardia is monomorphic, its origin can be ventricular tachycardia in a structurally abnormal heart, most commonly scar reentry in coronary artery disease or cardiomyopathies such as hypertrophic or dilated cardiomyopathy, or arrhythmogenic right. Cardiogenic shock in a patient with recurrent widecomplex. However, an arrhythmia arising from the atria or the atrioventricular junction will produce a broad complex if associated with ventricular preexcitation or bundle branch block. The electrophysiology service was consulted to assist with arrhythmia diagnosis and management. Classification of tachycardias with a broad qrs complex. Atrial or avnodal reentry tachycardia with preexcitation rare much more commonly in em, if qrs 200ms or rate is complex tachycardia at a rate of 214 bpm. It often presents a diagnostic dilemma for the physician particularly in determining its site of origin, which can be ventricular or supraventricular. Mar 30, 2002 this article continues the discussion, started last week, on ventricular tachycardias and also examines how to determine whether a broad complex tachycardia is ventricular or supraventricular in origin. Symptom onset occurred while he was taking his daily walk about 15 minutes prior to ems arrival.
Several algorithms have been developed to aid in this differentiation below. May 08, 2019 atrial tachycardia is usually a narrow complex tachyarrhythmia accounting for 515% of supraventricular tachycardias svts. Another evidence of av dissociation is the presence of occasional narrow complex beats in the midst of a wide complex tachycardia. As shown in fig 1, broad qrs tachycardia can be divided in three groups svt with bundle branch blockbundle branch block bbb may be preexisting or can occur when the refractory period of one of the bundle branches is reached because of the heart rate of the svt so called tachycardia related or phase 3 block. Unstable means that either important organ functions are affected or cardiac arrest is about to occur. A 12lead electrocardiography ecg performed during tachycardia demonstrated regular broad complex tachycardia with flutter waves marching across the screen, a qrs complex duration of 172 ms, and a right bundle branch block rbbblike morphology of 167 beatsmin fig. The differential diagnosis of a regular, monomorphic wide qrs complex tachycardia wct mechanism represents a great diagnostic dilemma commonly. The differentiation of wide qrs complex tachycardias presents a challenging diagnostic dilemma to many physicians despite multiple published algorithms and approaches. Dec 21, 2015 wide complex tachycardia treated with amiodarone and synchronized cardioversion a 55 year old male presents to ems with complaint of intermittent shortness of breath. Pdf when confronted with a tachycardia having a broad qrs complex, it is important to be able to differentiate. In this video, you will learn the essential basics. In ventricular tachycardia the rate is normally 120300 beatsminute. Ventricular tachycardia occurs in approximately 2 out of 10,000 people. Pdf diagnostic criteria of broad qrs complex tachycardia.
The electrocardiogram ecg is essential for the differential diagnosis of wide qrs complex tachycardia wct. Ventricular tachycardia is classified as nonsustained often defined as lasting less than 30 seconds or sustained. Wide qrs complex tachycardia wct is a rhythm with a rate of more than 100 beatsmin and a qrs duration of more than 120 milliseconds. Although there is no clear av dissociation, the presence of negative concordance in precordial leads, qrs duration longer than 160 milliseconds, and onset to nadir of s wave in lead v 1 longer than 100 milliseconds, all point toward ventricular tachycardia vt. Univariate analysis has identified several criteria that aid the differential diagnosis of broad complex. Every clinician taking care of cardiac patients should be able to diagnose them. The management of tachycardia depends on its type wide complex versus narrow complex, whether or not the person is stable or unstable, and whether the instability is due to the tachycardia. Broad complex tachycardia bct is defined as a heart rate 100 bpm with a qrs complex 0. We present a case of a 54yearoldfemale who recently underwent placement of an implantable cardioverter.
Patient presenting with a tachyarrhythmia is a common finding in the emergency room. If the morphology changes, if the complex changes its look then wed call that a polymorphic widecomplex tachycardia, and the treatments a little different. Supraventricular origin 058 sinus tachycardia with raterelated left bundle branch block. Simple electrocardiographic criteria for rapid identification of wide. Wide complex tachycardia ventricular tachycardia or not ventricular tachycardia, that remains the question.
Overall, this is a consensus document that includes evidence and expert opinions from several countries. In addition to hypertension and type ii diabetes, he had previously suffered three myocardial infarctions and had undergone both surgical and percutaneous coronary revascularization. In broad complex tachycardias the qrs complex is longer than 120 ms three small squares on the ecg. Diagnosis and treatment of widecomplex tachycardias. Presentation a ventricular origin for a broad complex tachycardia is suggested if the patient is aged over 35 years and has a history of ischaemic heart disease or. Wide complex tachycardias are a commonly encountered entity in coronary care units, intensive care units and emergency departments. Broad qrs complex tachycardia still presents a diagnostic challenge when confronted with a 12lead electrocardiogram ecg. The rate is 125 and the qrs duration is 160 msec, with broad r waves in leads i, avl, and v56 indicating lbbb. During catheter placement for the electrophysiology study, he developed broad complex tachycardia of rbbb morphology with a cycle length cl of 264 milliseconds and negative hv interval. The differentiation of wide qrs complex tachycardias.
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