Case Report : A 48 Years Old Male with Wide QRS

Complex Tachychardia

Yusuf SA1, Jaya I P P2

1
Internship Doctor in Bhakti Rahayu Hospital Denpasar, Bali, Indonesia,
2
Cardiologist at Bhakti Rahayu Hospital Denpasar, Bali, Indonesia

Introduction : Wide QRS complex tachycardia (WCT) defined as a a rhythm with a rate >100/min
with QRS duration ≥ 120 ms.1 The most common cause of WCT is ventricular tachycardia (VT) and
accompanied by supraventricular tachycardia with abberant conduction (SVT-A).1 The differential
diagnosis of a regular, monomorphic wide QRS complex tachycardia (WCT) mechanism represents a
significant problem commonly encountered by the practicing physician, because many of these ECG
criteria are complicated.1

Case Illustration : A 48 years old male presented to emergency department with shortness of breath
(NYHA class III) since one day ago. It’s accompanied with paroxysmal nocturnal dyspnea, orthopnea,
palpitation, typical chest pain and epigastric pain. This is the second time the patient experiencing the
same symptoms. He had a medical history of stroke and uncontrolled hypertension. Upon physical
examination, blood pressure 169/100 mmHg, heart rate 242 beats/min regular, respiration 39 beats/min,
oxygen saturation 92%. From cardiac examination, there was no murmur and gallop. Electrocardiogram
result revealed there was ventricular tachycardia on inferior lead and supraventricular tachychardia on
anterolateral. Initial diagnosis of the patient was ventricular tachychardia and acute heart failure with
differential diagnosis supraventricular tachychardia abberancy and hypertensive heart disease. The
therapy was given by the cardiologist and he was admitted to the high care unit.
Discussion : There are several algorithms (Traditional, Brugada and Vereckei) that can be used to
differentiate VT and SVT-A.1,2,3,4 According to Brugada algorithm, there are 4 criteria for VT that are
sequentially considered. The absence of an RS complex in all precordial leads, the longest R to S
interval > 100ms in any precordial lead, A-V dissociation, and morphology criteria for VT are present
in leads V1-V2 and V6.1,2,3,4 From the result of patient’s ECG, RS complex are presence in all precordial
leads. Then, the interval of R to S in any precordial leads are < 100ms. However, there is an A-V
dissociation in which P wave does not followed by complex QRS. So, by using systematic Brugada’s
algorithm it is suggested that the diagnosis of the patient are more likely to be ventricular
tachycardia.1,2,3,4
Figure 1. Ventricular Tachycardia in inferior lead and supraventricular tachycardia in anterolateral lead
with QRS rate 269 beats/min

Conclusion : The differential diagnosis of wide complex tachycardia remains a daunting task for
general practicioner. In order to encounter these situation, until it can be proved otherwise, it is best for
these kind of patient to be treated as ventricular tachycardia.

Keywords : Ventricular Tachycardia, Supraventricular Tachycardia with abnormal intraventricular

conduction, Wide QRS Complex Tachycardia

References :
1. Vereckei A. Current Algorithms for the Diagnosis of wide QRS complex Tachycardias. Current
Cardiology Reviews. 2014.vol 10;3. Pg 262-276.
2. Blomstrom-Lundqvist C, Scheinman MM et al. AHA/ACC/ESC Guidelines for Management of
Patients with Supraventricular Arrhythmias. AHA/ACC/ESC Practice Guidelines.2003. Pg 2-
48.
3. Alzand BSN, Crijns HJGM. Diagnostic Criteria of Broad QRS Complex Tachycardia: decades
of evolution. European Society of Cardiology. 2011.13. Pg 465-472.
4. Chai Q, Liu G, Zhang HJ, Zheng M. The Value of Brugada Algorithm in the Differential
Diagnosis of Broad QRS Complex Tachycardia: A Meta Analysis. J Cardiovasc Dis Diagn
2018, 6:2. Pg 1-7.