Wide Complex Tachycardia

Transcription

1 Arrhythmias on 12 Lead ECG Wide Complex Tachycardia Walid Saliba, MD, FHRS Director, EP Labs Heart and Vascular Institute Cleveland Clinic

2 Disclosures None related to this presentation

3 55 year old male, remote MI 10 years ago Presenting with palpitations and mild dizziness (BP 100/60 mmhg) No Chest Pain

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6 General Concepts: QRS is Ventricular activation Normal Ventricular activation : Activation of the ventricles through the HPS (His + Both BB) results generally in a narrow QRS complex: Abnormal Ventricular activation: Activation of the ventricle from one site only results generally in a wide QRS complex.

7 SVT AT AFIB RA LA RA LA RV LV RV LV RA LA RA LA Flutter circuit AVNRT Circuit RV LV RV LV A Flutter AVNRT

8 SVT (cont d) :AVRT RA LA RA LA ORT RV LV RV LV ART ORT

9 Mechanisms underlying WCT Tachycardia originating in the ventricle (VT) Tachycardia originating above the ventricle (SVT) but with abnormal ventricular activation Bundle Branch Block Accessory Pathway Ventricular paced rhythm Recording artifact

10 Differential diagnosis of WCT VT : 80% of all WCT SVT with abnormal ventricular activation: 15-20% of WCT With BBB aberration(rbbb/lbbb) With antegrade conduction via an AP (WPW): 1-5% of WCT Antegrade conduction via a bystander AP Antidromic reciprocating tachycardia: ART With IVCD With Drugs : Na channel blockers.(flecainide) With Electrolytes abnormalities: K +

11 A Fib/AT WCT: SVT with BBB A Flutter RA LA RA LA RV LV RV LV RA LA RA LA RV LV RV LV AVNRT ORT

12 WCT: SVT with preexcitation A Fib/AT A Flutter RA LA RA LA RV LV RV LV RA LA RA LA Acce ssory Pa thway RV LV RV LV AVNRT ART

13 Differential diagnosis of WCT (cont d) Ventricular Paced rhythm SVT with atrial tracking PMT Artifact

14 WCT: Ventricular Paced Atrial Tracking PMT A Se nse V Pace RA LA A Sense V Pac e RA LA SVT Pac emaker lead RV LV RV LV

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16 Differential diagnosis of WCT (cont d) Ventricular Paced rhythm SVT with atrial tracking PMT Artifact

17 WCT: Artifact

18 WCT: Artifact

19 Diagnosis Clinical presentation EKG criteria Provocative maneuvers

20 60 year old male, h/o MI 5 years ago Presenting with sudden onset palpitations, SOB and dizziness (BP :85/60 mmhg)

21 Diagnosis: Clinical Presentation, History WCT in patients with prior history of structural cardiac disease Ventricular Tachycardia Ventricular Tachycardia Ventricular Tachycardia Ventricular Tachycardia Ventricular Tachycardia Ventricular Tachycardia Ventricular Tachycardia Ventricular Tachycardia Ventricular Tachycardia Ventricular Tachycardia Ventricular Tachycardia Ventricular Tachycardia Ventricular Tachycardia Supraventricular Tachycardia

22 Diagnosis: Clinical Presentation Physical Exam Hemodynamic instability is a poor discriminating factor Hemodynamic stability depends on rate, underlying cardiac disease, ventricular function, concomitant medication.

23 Diagnosis: EKG criteria Tachycardia rate QRS Duration Regularity QRS Axis AV dissociation. QRS precordial concordance Absence of precordial RS pattern QRS morphology Criteria Capture and fusion beats.

24 Diagnosis: EKG criteria Regularity: Not a useful criterion VT can be irregular especially in patients on antiarrhythmic medication.

25 F F

26 Diagnosis: EKG criteria QRS Concordance in Precordial leads Predictive of VT: High specificity(>90%). Low sensitivity: Present in <20% of VT s. Can be seen in Preexcited Tachycardia (+ve Concord.) 1-2%.

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29 Diagnosis: EKG criteria AV dissociation The most useful criterion. Is absent in almost all SVT. Occurs in up to 60% of VT s but is only apparent on the surface ECG in 20-30%. (sensitivity=20%, specificity=99%)

30 Diagnosis: EKG criteria AV dissociation Maximize atrial recordings: Esophageal lead Atrial pacemaker wires post cardiac surgery Change arm lead position

31 Diagnosis: EKG criteria AV dissociation 1:1 AV association present in 30% of VT s and cannot be differentiated from SVT. Transient AV dissociation with CSM or IV adenosine.

32 A A A A A

33 A A A A A

34 AV dissociation with Capture and Fusion beats * * * * * * * VT C F C Narrow complex beats with a shorter CL than the tachycardia. Indicates WCT is VT. May be slightly early; usually intermediate in width Not pathognomonic for VT: (PVC during SVT with BBB)

35 Diagnosis: EKG criteria Morphology criteria (precordial leads): QRS polarity : RBBB or LBBB LBBB morphology: Predominantly Negative QRS deflection in V1 RBBB morphology: Predominantly Positive QRS deflection in V1

36 Normal Conduction 4 V6 2 V

37 Normal Conduction RBBB V6 4 V6 V1 4 2 V

38 Normal Conduction RBBB V6 4 V6 V V6 V V1 1 LBBB

39 Morphology criteria RBBB LBBB V1 V6

40 Rapid Downstroke Triphasic RS QS Broad r slurring/notching rsr rsr rsr Mono R No Q wave Triphasic: qrs RS>1 rs (R<S) Mono R QS Mono R Broad R+ any S qr rr Any Q: qr, QS, QR QR

41 V1 VT vs SVT: RBBB Morphology Criteria Monophasic R Favors VT V1 Favors SVT Triphasic QR RS R > r V6 R/S < 1 V6 Triphasic QS QR Monophasic R Adapted from Wellens et al, AJM 64:27-33, 1978

42 VT vs SVT: LBBB Morphology Criteria V1 or V2 V6 R in V1 or V2 > 40 ms in duration >60 msec from QRS onset to S nadir in V1 or V2 Notched downstroke S wave in V1 or V2 Any Q in V6

43 V1 V6

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45 Notching

46 V1 V6

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48 WCT: Brugada s Criteria I 4 level algorithm Prospectively analyzed in 554 WCTs (384 VT, 170 SVT) with EP diagnosis Sensitivity.987; Specificity.965

49 ABSENCE OF AN RS COMPLEX IN ALL PRECORDIAL LEADS? YES NO VT NEXT QUESTION R TO S INTERVAL > 100 MS IN ONE PRECORDIAL LEAD? YES NO VT NEXT QUESTION AV DISSOCIATION? YES NO VT NEXT QUESTION MORPHOLOGY CRITERIA FOR VT PRESENT BOTH IN V1-2 AND V6? YES NO VT SVT WITH ABERRANT CONDUCTION

50 ABSENCE OF AN RS COMPLEX IN ALL PREC. LEADS? YES NO VT NEXT QUESTION R TO S INTERVAL > 100 MS IN ONE PRECORDIAL LEAD? YES NO VT NEXT QUESTION ATRIO-VENTRICULAR DISSOCIATION? YES NO VT NEXT QUESTION MORPHOLOGY CRITERIA FOR VT IN V1-2 AND V6? YES NO VT SVT WITH ABERRANCY

51 Diagnosis: EKG criteria Patients with PPM Ventricular preexcitation have QRS complex morphology during SVT that would satisfy the morphology criteria for VT, since activation of the ventricle proceeds from one single point in the ventricle, in a way similar to ventricular tachycardia.

52 WPW: Left side AP

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55 Diagnosis: EKG criteria Miscellaneous conditions QRS during WCT narrower than NSR: suggests VT. Contralateral BBB in NSR and WCT: suggests VT. If rapid irregular WCT with beat-beat QRS duration variation, suspect AFIB+ WPW.

56 FBI

57 Diagnosis :Provocative maneuvers : Vagal maneuvers: Carotid Sinus Massage, Valsalva. IV drugs: Adenosine (short t 1/2 ), B-Blockers 1. Tachycardia slowing or termination suggests SVT (rare VT) 2. May elicit VA block : suggests VT 3. AV block uncovers background A activity Do NOT give verapamil

58 Adenosine: VA block 2:1 Adenosine

59 Adenosine: Uncovering Background Atrial Activity

60 Special Cases Misclassification of SVT for VT Preexcited tachycardia Misclassification of VT for SVT BBR-VT Narrow QRS VT Idiopathic LV-VT

61 BBR-VT RA LA RV LV

62 ILV-VT

63 Conclusion Despite Multiple tools, diagnosis is still difficult If configuration is not compatible with any form of aberration, than it is likely VT.

64 Conclusion (cont d) If structural heart disease is present, WCT is most likely VT Certain type of treatment may potentially worsen the patient s situation. So if unsure of the diagnosis, treat as VT.

65 END