Wide QRS Complex

Tachycardia
Yoga Yuniadi
Department of Cardiology and Vascular Medicine,
Faculty of Medicine, Universitas Indonesia
VT or Others?
VT or SVT ?
 Definitions
Wide QRS complex tachycardia is a rhythm with a rate of
≥100 bpm and QRS duration of ≥ 120 ms
VT : 80% of Wide QRS Complex Tachycardia
SVT with abberancy 15 to 20%
SVT with bystander preexcitation and antidromic reentrant
tachycardia: 1% to 6%
 Causes of WQRS TACHYCARDIA
VT MACROREENTRANT VT

FOCAL VT

SVT WITH ABERRANCY FUNCTIONAL BBB

PREEXISTENT BBB

PREEXCITED SVT ANTIDROMIC AVRT

AT OR AVNRT WITH BYSTANDER BYPASS TRACT

ANTIARRYTHMIC DRUGS CLASS 1A,CLASS 1C

AMIODARONE

ELECTROLYTE ABNORMALITIES HYPERKALEMIA

 Why QRS is wide?

A widened QRS (≥120 msec) occurs when

ventricular activation is abnormally slow
Arrhythmia originates outside of the normal
conduction system (ventricular tachycardia)
Abnormalities within the His-Purkinje system
(supraventricular tachycardia with aberrancy)
Pre-excited tachycardias: supraventricular
tachycardias with antegrade conduction over an
accessory pathway into the ventricular myocardium .
 MORPHOLOGY
LBBB morphology-QRS complex duration ≥ 120 ms
with a predominantly negative terminal deflection
in lead V1

RBBB morphology-QRS complex duration ≥ 120 ms

with a predominantly positive terminal deflection
in V1
 RBBB morphology wide QRS
tachycardia
• VT
• Structurally normal heart
• LVOT VT
• Fasicular VT
• Abnormal heart
• LV myocardial VT
• Bundle Branch Reentrant VT

• SVT
• SVT with pre existing RBBB
• SVT with functional RBBB
 LBBB morphology wide QRS
tachycardia
• VT
• Structurally normal heart
• RVOT VT
• Abnormal heart
• Right ventricular myocardial VT
• ARVD

• SVT
• Mahaim fibre mediated tachycardia
• SVT with preexisting LBBB
SVT vs VT : Clinical history
 DURATION

• Duration of the tachycardia — SVT is more likely if

the tachycardia has recurred over a period of more
than three years
 SVT vs VT
 AV dissociation
-cannon A waves
-variable intensity of S1

 Termination of WCT in response to maneuvers like

Valsalva, carotid sinus pressure, or adenosine favor
SVT
 Maneuvers
• The response of the arrhythmia to maneuvers may
provide insight to the mechanism of the WCT

• Carotid sinus pressure — Enhances vagal tone ,

depresses sinus and AV nodal activity
 VT
• Unaffected by vagal maneuvers such as carotid
sinus pressure or valsalva

• May slow or block retrograde conduction.

Exposes AV dissociation

Rarely, VT terminates in response to carotid sinus

pressure.
 Rate

• Limited use in distinguishing VT from SVT.

 Regularity

Marked irregularity of RR interval occurs in

atrial fibrillation (AF) with aberrant
conduction and polymorphic VT
 Axis
• A right superior axis (axis from -90 to ±180º)- “northwest"
axis, strongly suggests VT . (sensitivity 20%,specificity
96%)

• Exception -antidromic AVRT in Wolff-Parkinson-White

(WPW) syndrome .
 AXIS
• Compared to the axis during sinus rhythm, an axis
shift during the WCT of more than 40º suggests VT
.

• In a patient with a RBBB-like WCT, a QRS axis to

the left of -30º suggests VT.

• In a patient with an LBBB-like WCT, a QRS axis to

the right of +90º suggests VT .
 QRS duration
• In general, wider QRS favors VT.
• In a RBBB-like WCT, a QRS duration >140
msec suggests VT
• In a LBBB-like WCT, a QRS duration >160
msec suggests VT
• In an analysis of several studies, a QRS
duration >160 msec was a strong predictor
of VT (likelihood ratio >20:1)
• A QRS duration <140 msec does not
exclude VT
 Concordance
• Concordance is present when the QRS complexes
in all six precordial leads (V1 through V6) are
monophasic with the same polarity.

• Either -entirely positive with tall, monophasic R

waves, or entirely negative with deep monophasic
QS complexes.

• If any of the six leads has a biphasic QRS (qR or RS

complexes), concordance is not present.
• Negative concordance is strongly
suggestive of VT
• exception:SVT with LBBB aberrancy may demonstrate negative
concordance

• Positive concordance -also indicates

VT
• exception: antidromic AVRT with a left posterior accessory pathway
 Concordance
• Presence of concordance strongly suggests VT
(90 percent specificity)

• Absence is not helpful diagnostically

(approximately 20 percent sensitivity)

• Higher specificity for Positive concordance

compared to negative concordance(specificity
95% vs 90 %)
Negative concordance
Positive concordance
 AV dissociation
• AV dissociation is characterized by atrial activity
that is independent of ventricular activity

• Atrial rate slower than the ventricular rate

diagnostic of VT.

• Atrial rate that is faster than the ventricular rate

- SVTs.
 Absence of AV dissociation in VT

• AV dissociation may be present but not obvious on the

ECG.

• The ventricular impulses conduct backwards through

the AV node and capture the atrium ( retrograde
conduction), preventing AV dissociation.
 Dissociated P waves

• PP and RR intervals are different

• PR intervals are variable
• There is no association between P and QRS
complexes
• The presence of a P wave with some , but not all, QRS
complexes
 Fusion beats
• Fusion beat-produced by fusion of two
ventricular activation wavefronts characterized
by QRST morphology intermediate between
normal and fully abnormal beat.

• Fusion beats during a WCT are diagnostic of AV

dissociation and therefore of VT.

• Low sensitivity(5-20%)
 Capture beats
Capture beats, or Dressler beats, are QRS
complexes during a WCT that are identical to the
sinus QRS complex .

Implies that the normal conduction system has

momentarily "captured" control of ventricular
activation from the VT focus.

Fusion beats and capture beats are more

commonly seen when the tachycardia rate is slower
 If old ecg available…
• Ideal QRS configuration between baseline and
WQRST-suggest SVT(exception :bundle branch
reentrant VT)

• Contralateral BBB patterns in baseline vs

WQRST ECGs-suggest VT

• WQRST complexes narrower than baseline

ECG-suggest VT(the baseline ecg must have a
bundle branch block pattern)
 Also look for….
• VPCs

• Evidence of prior MI

• QT interval

• ECG clues to any other structural heart disease

 Diagnostic Algorithm
• The ACC algorithm
• ECG algorithms to differentiate wide QRS-complex
tachycardias
• Brugada algorithm
• Ultrasimple Brugada criterion: RW to peak Time
(RWPT)
• Vereckei aVR algorithm
• Griffith (Bundle Branch Block) algorithm
• Wellen’s Criteria
 Sensitivity and Specificity

Algorithm Sensitivity Spesificity

Brugada 89 59.2
Lead II R-wave peak time 60 82.7
(Ultra-simple Brugada)
Vereckei 87.1 48
Bayesian 89 52
Grifith 94.2 39.8

Jastrzebski M, et al. Europace. 2012;14(8):1165-71

ACC
Brugada algorithm

Brugada P. Ciculation 1991

Step 1
Step 2
Step 3
 Step 4:
LBBB - type wide QRS complex
SVT VT

R wave >30ms
small R wave notching of S wave

V1

fast downslope
of S wave > 70ms

V6 Q wave
no Q wave
 V6 in LBBB type QRS
• True LBBB
Monophasic R with slow upstroke

• VT
qR or QS pattern
 Step 4:
RBBB - type wide QRS complex
SVT VT

rSR’ configuration monophasic R wave qR (or Rs) complex

V1
or

R/S > 1 R/S ratio < 1 QS complex

V6 or
 “R/S ratio in V6 rule”
• R/S ratio in RBB type wide QRS tachycrdia less
than one, favors VT

Sensitivity-0.73
Specificity-0.79
Positive predictive value 0.9
 Josephson’s sign
• Notching near the nadir of the S-wave
• Suggest VT
Rabbit’s ear
 Wellens Criteria

• QRS width > 140 msec

• Left axis deviation

• AV dissociation

• Configurational characteristics of the QRS

morphology
 Ultrasimple Brugada criterion

R wave peak time in Lead II

Duration of onset of the QRS to
the first change in polarity
(either nadir Q or peak R) in lead
II.
If the RWPT is ≥ 50ms the
likelihood of a VT very high
(positive likelihood ratio 34.8)
Vereckei Algorithm
 Take Home Messages
• WCT is remain a diagnostic problem
• Do all necessary effort to get an accurate
diagnostic: from clinical to electrocardiographic
perspective
• Use the most familiar algorithm but realize its
limitation
• Have a second check with different algorithm
• Remember: Most of the time WCT need prompt
treatment!!
Thank You