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VT or Not VT - Edited
VT or Not VT - Edited
VT or Not VT - Edited
Ventricular tachycardia (VT) is one of the differential diagnosis of monomorphic wide QRS
complex tachycardia (WCT). It arises distal to the bifurcation of the His bundle in the specialized
conduction system, ventricular muscle or combination of both tissue types. Mechanisms of VT include
disorder of impulse formation (enhanced automaticity or triggered activity) and conduction (reentry).
The most common of cause of WCTs is VT which accounts for 80% of all cases of WCT,
followed by supraventricular tachycardia (SVT) with aberrancy conduction or pre-existing block that
account for 15-20%. The minority (1-6%) of WCTs is SVT with bystander preexcitation and antidromic
atrioventricular reentrant tachycardia.
Accurate diagnosis of WCT requires information obtained from the history, physical
examination, response to certain maneuvers or medications and careful inspection of the ECG.
Comparison of the ECG during the tachycardia with that recorded during sinus rhythm can also provide
useful information.
When consider about the patients clinical characteristic, manifestation and history, WCT
in a patient older than 35 years is likely to be VT (positive predictive value of up to 85%) while SVT is
more likely in the younger patient (positive predictive value of 70%). The severity of symptom during
tachycardia is not useful in determining the tachycardia mechanism because of the symptoms during
WCT are primarily depend on how fast of the heart rate, the presence and extent of LV dysfunction.
One important clinical information which is strongly suggests VT as the cause of WCT is that the
presence of underlying structural heart disease, especially coronary artery disease and previous MI.
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For the physical examination information, the important point for the physical examination
during an episode of WCT is to evaluate whether the patients have unstable hemodynamic status in
order to prompt giving them appropriate life safety therapy. For the stable hemodynamic WCT, sign
of AV dissociation, intermittent cannon A wave or if present on ECG, is strongly suggest VT, although
its absence is less helpful.
For electrocardiographic inspection, there are several ECG features help differentiate VT
from SVT including the QRS axis, the QRS duration and the QRS morphology (Table 2.).
AV Relationship
Dissociated P waves
Fusion beats
Capture beats
A/V ratio 1
QRS Duration
160 msec with LBBB pattern
140 msec with RBBB pattern
QRS during WCT is narrower than in NSR
QRS Axis
Axis shift of 40 degrees between NSR and WCT
Right superior (northwest) axis.
Left axis deviation with RBBB morphology
Right axis deviation with LBBB morphology
Table 2. ECG criteria favoring ventricular tachycardia. Modified from Issa Z, Miller JM, Zipes DP. (2009). Clinical
arrhythmology and electrophysiology: a companion to Braunwalds Heart Disease. Philadelphia. PA: Suanders
Elsevier.
However, there is difficult to apply a single criteria for diagnosis of WCT, because most
patients will have some, but not all, of the features described. Several algorithm have been proposed
to guide integrating each ECG features into a diagnosis strategy. One important point is that we have
to know the limitation of specific criteria proposed. Generally, conditions that effect to the QRS
morphology such as history of prior MI, preexcited tachycardia, antiarrhythmic medication usage,
precordial lead placement, heart transplantation status and the presence of congenital heart disease
should be taken into account while applying these elements.
Brugada algorithm is one of the most commonly used algorithm for diagnosis of VT
(Figure 1 and Table 3.). The reported sensitivity and specificity from different authors were range from
79-92% and 43-70%, respectively.
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Absence of an RS complex
in all precordial leads?
yes No
Yes
No
sens = .66 VT
spec = .98
Atrioventricular
dissociation?
yes No
Yes No
sens = .965
spec = .987
RS < 1 in V6 , QS in V6 Any Q in V6
Table 3. Classical Wellens criteria favouring VT. Modified from Becker S.N. Alzand* and Harry J.G.M
Crijns*Europace (2011) 13, 465472
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A newer algorithm has been proposed since 2008 by Vereckei A and colleagues. This new
algorithm was studied and based solely on QRS morphology in lead aVR with the principle of
differences in the direction and velocity of the initial and terminal ventricular activation during WCT
caused by VT and SVT (Figure 2.). The overall accuracy of the aVR algorithm was 91.5% which is
superior to the Brugada algorithm (84.8%). However, some limitations remaining for the new aVR
criteria including the inability to differentiate preexcited tachycardia from VTs and the possible
exception of the presence of initial R wave in lead aVR e.g. in case of inferior wall MI.
Yes No
Accuracy
98.6%
Yes No
Yes No
VT
Vi /Vt 1
Accuracy
86.5%
Yes
No
Accuracy VT
89.3%
SVT
Figure 2. New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia. SVT supraventricular
tachycardia; VT ventricular tachycardia. (From Vereckei A, Duray G, Szonsi G, et al: New algorithm using only lead aVR for
differential diagnosis of wide QRS complex tachycardia). Modified from Issa Z, Miller JM, Zipes DP. (2009). Clinical arrhythmology and
electrophysiology: a companion to Braunwalds Heart Disease. Philadelphia. PA: Suanders Elsevier.
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