ECG OF THE WEEKK.M.JEYABALAJI

Dr.P. VIJAYARAGAVAN’S UNIT

HISTORYA 22 yr male patient came with

complaints ofAcute onset breathlessnessPalpitationProfuse sweatingVague chest discomfort

For past 1 hour

EXAMINATION

Dyspnoeic, tachypnoeic, Pulse- 180/ min REGULARBP- 90/ 60 mmhgJVP- ---CVS- s1,s2 heardRS – NVBSP/A- softCNS- NFND

ADMISSION ECG

CHEST LEADS

FINDINGSTACHYCARDIAREGULAR RHYTMRATE- 200/minAXIS – EXTREME NORTH ( northwest)WIDE QRS COMPLEX RBBB PATTERN IN V1

DD FOR WIDE COMPLEX TACHYCARDIA

• Ventricular tachycardia (VT)• Supraventricular tachycardia (SVT) with Aberrancy• SVT with drug or electrolyte induced QRS widening

APPROACH WIDE COMPLEX TACHYCARDIA

REGULAR/IRREGULAR

AV DISSOCIATION

CLASSICAL BUNDLE BRANCH MORPHOLOGY

BRUGADA CRITERIA

AVR CRITERIA

BRUGADA CRITERIAYES

Absence of RS complex in V1 – V6

VT

RS complex duration > 100 ms VT

AV dissociation VT

Morphology criteria VT

BRUGADA CRITERIA

MORPHOLOGY CRITERIAFor RBBB-type complexes

Is there an rSR’ morphology in V1? Is there an RS complex in V6 (small

septal q OK)? Is the R/S ratio in V6 > 1? For LBBB-type complexes

Is there an rS or QS complex in V1 and V2? Is the onset of the QRS to the nadir of the S in V1 <

70 ms? Is there an R wave in lead V6 without a

Q?

AVR CRITERIAPresence of an initial R wave Width of an initial r or q wave >40 ms,

Notching on the initial downstroke of a predominantly negative QRS complex

Ventricular activation–velocity ratio (vi/vt), the vertical excursion (in millivolts) recorded during the initial (vi) and terminal (vt) 40 ms of the QRS complex. When any of criteria 1 to 3 was present, VT was diagnosed; when absent, the next criterion was analyzed. In step 4, vi/vt >1 suggested SVT, and vi/vt ≤1 suggested VT.

VENTRICULAR TACHYCARDIAAbsence of typical RBBB or LBBB morphologyExtreme axis deviation (“northwest axis”)Very broad complexes (>160ms)AV dissociation (P and QRS complexes at

different rates)Capture beats — occur when the sinoatrial

node transiently ‘captures’ the ventricles, in the midst of AV dissociation, to produce a QRS complex of normal duration.

Fusion beats — occur when a sinus and ventricular beat coincides to produce a hybrid complex.

Positive or negative concordance throughout the chest leads, i.e. leads V1-6 show entirely positive (R) or entirely negative (QS) complexes, with no RS complexes seen.

Brugada’s sign–  The distance from the onset of the QRS complex to the nadir of the S-wave is > 100ms

Josephson’s sign – Notching near the nadir of the S-wave

VT

CAPTURE BEAT FUSION BEAT

BRUGADA SIGN , JOSEPHSON SIGN

NEGATIVE CONCORDANCE POSITIVE

CONCORDANCE

SVT WITH ABBERANCY• Any SVT can be conducted with aberrancy:

– Sinus Tachycardia– Atrial tachycardia– Atrial flutter– Atrioventricular nodal reentrant tachycardia (AVNRT)– Junctional Tachycardia– Orthodromic Atrioventricular Reentrant Tachycardia (AVRT)

VT AGAINST VTNorthwest axisPseudo RBBB

morphologyBRUGADA

CRITERIAAVR CRITERIAVery broad QRS

complex > 160 ms

Hemodynamically stable

No previous MI, CMVi/Vt > 1No fusion, capture

beat. no concordance

FASCICULAR VT

SUPERIOR AXIS PSEUDO RBBB MORPHOLOGYHEMODYNAMICALLY STABLE

TAKE HOME MESSAGE

No criteria is 100% sensitive nor specific

Never go blindly by ECGGive equal imortance to history,

clinical presentation, VitalsIf you are 100% sure that it is SVT,

then proceed.Having even 1% doubt, then treat it

as VT

THANK YOU