wide qrs tachycardia - ddx...morphology criteria tachycardia with a right bundle branch block-like...
TRANSCRIPT
Wide QRS Tachycardia - DDx
•VT
•SVT with Aberrancy•Pre excited SVT
•Antidromic AVRT
•Drugs
•Electrolytes
CriteriaScoresAlgorithms…
The Wide QRS Toolkit
• AV dissociation
• (Rate ?)
• QRS:
• Axis
• Slopes
• Structure
The Wide QRS Toolkit
• AV dissociation
• (Rate ?)
• QRS:
• Axis
• Slopes
• Structure
Fusion Beat
Capture Beat
QRS
• Axis
• Slopes
• Structure
QRS Axis - In Support of VT:
• Concordance
• NW axis
• RBBB + Left axis
• LBBB + Right axis
Concordance
Negative Concordance Positive ConcordanceNegative Positive
(+) concordance
‘Northwest’ axis
LBBB-right axis
RBBB-left axis
QRS
• Axis
• Slopes
• Structure
• Initial 20 ms = NSR• )Initial r in LBBB>30
ms(• Vi/Vt<1 (40ms)• RWPT L2 > 50 ms• )LBBB RS>60 ms(• Any RS>100 ms
Slopes
60
3020
S
40R
40
50
100
20
R
• Initial 20 ms = NSR
Slopes
First 20 ms (0.5 mm!) identical to sinus beat
Normal
AberrantVPB
First 20 ms (0.5 mm!) identical to sinus beat
40
40
Slopes
• Initial 20 ms = NSR• Initial r in LBBB>30
ms• Vi/Vt<1 (40ms)• RWPT L2 > 50 ms• LBBB RS>60 ms• Any RS>100 ms
• Initial 20 ms = NSR• Initial r in LBBB>30
ms• Vi/Vt<1 (40ms)• RWPT L2 > 50 ms• LBBB RS>60 ms• Any RS>100 ms
Slopes
R
In Lead II:R Wave Peak Time (RWPT) > 50 ms
50
II
• Initial 20 ms = NSR• Initial r in LBBB>30 ms
• Vi/Vt<1 (40ms)• RWPT L2 > 50 ms• (LBBB RS>60 ms(
• Any RS>100 ms
Slopes
100S
R
In any lead:RS>100 ms
QRS
• Axis
• Slopes
• Structure
rsR`
rSR`
rsr`
sR
SR
Rs
Triphasic
V6
V1,2
LBBB
Q
Biphasic RBBB
r30
Initial R in aVR
‘Rabbit Ear’ sign
Very Wide QRS
The Vereckei aVR OnlyAlgorithm
2008
• AV dissociation left out
(Inferior/apical origin)
Typical examples of
aVR
40
40
The Vereckei aVR Only Algorithm
Summary: The Wide QRS Toolkit
• AV dissociation
• (Rate ?)
• QRS:
• Axis
• Slopes
• Structure
• Vereckei aVR Only Algorithm
Thank you
The Brugada Algorithm
1991
Onset to nadir of QRS >
100 ms
Any precordial lead
Morphology Criteria
Tachycardia with a right bundle branch block-like QRS
Lead V1Monophasic R or QR or RS favors VTTriphasic RSR' favors SVT
Lead V6R to S ratio <1 (R wave smaller than S wave) favors VTR to S ratio >1 (R wave larger than S wave)favors SVTQS or QR favors VTMonophasic R favors VTTriphasic favors SVT
Tachycardia with a left bundle branch block-like QRS
Lead V1 or V2Any of following R >30 msec, >60 msec to nadir S, notched S favors VT
Lead V6Presence of any Q wave, QR or QS favors VTThe absence of a Q wave in lead V6 favors SVT
…Does all this really matter?
•What happens if we make a mistake?
•Verapamil
•Adenosine?
•ICD?