Vt vs svt ab copy

VT

1. VT versus SVT with aberrancy

2. Differential Diagnosis of Wide Complex
Tachycardia
Ventricular tachycardia
Supraventricular tachycardia:
with aberrancy in the His-Purkinje system
with anterograde accessory pathway conduction
with bizarre baseline QRS
in presence of drug effect or electrolyte imbalance
Ventricular pacing

4. From Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, et al: ACC/AHA/ESC guidelines for the management of patients with supraventricular
arrhythmias—executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the
European Society of Cardiology Committee for Practice Guidelines [Writing Committee to Develop Guidelines for the Management of Patients With
Supraventricular Arrhythmias]. Circulation 108:1871, 2003

7. Sandler and Marriott Criteria (1965)
RBBB morphology - If the initial 20 ms of the QRS are the same
in WCT as in sinus rhythm, SVT is favoured by 20:1, with a
positive predictive value (PPV) of 92 %. If the sinus rhythm ECG
is available for this analysis.
RBBB morphology - An rSR’ where S crosses baseline = SVT.
The presence of such a QRS in a RBBB WCT favours SVT by
at least 11:1 with a PPV of 91 %.
Sandler IA, Marriott HJ. The Differential Morphology of Anomalous Ventricular Complexes of Rbbb-Type in Lead V; Ventricular Ectopy
Versus Aberration. Circulation 1965;31:551–6

8. RBBB morphology - Triphasic QRS = SVT. A triphasic QRS in V1
favoured SVT with a PPV of 92 , with specificity ≥90%.
RBBB, LBBB morphology- Precordial concordance = VT.
A QRS, which is predominantly positive or predominantly
negative in every precordial lead, - favours VT.
Subsequent studies have confirmed this with specificity of 95–100 % and a
PPV of 89–100 %.
Sandler IA, Marriott HJ. The Differential Morphology of Anomalous Ventricular Complexes of Rbbb-Type in Lead V; Ventricular Ectopy
Versus Aberration. Circulation 1965;31:551–6

9. The Wellens Criteria of Right Bundle Branch Block
Wellens et al. analysed 70 sustained VT and 70 SVT
episodes with aberrancy, all proven at
electrophysiological study
Wellens HJ, Bar FW, Lie KI. The value of the electrocardiogram in the differential diagnosis of a tachycardia with a widened QRS complex.
Am J Med 1978;64:27–33

10. QRS duration >140 ms = VT
The original data showed a specificity and PPV of 100 % for VT
Subsequent studies found this less certain, with specificities of 57–75 %
and PPV of 89 %
Left axis = VT.
This was originally discussed without regard to bundle block morphology,
but it is most robust for RBBB WCT where the original PPV was 94 %.
Later studies have found PPVs of 88–94 %.
With extreme left axis (more negative than -90 °), the PPV is 98 %
Wellens HJ, Bar FW, Lie KI. The value of the electrocardiogram in the differential diagnosis of a tachycardia with a widened QRS complex.
Am J Med 1978;64:27–33

11. AV dissociation = VT
Of all criteria, this is the most secure
Six separate, large cohorts have all found 100 % specificity
and 100 % PPV for true
It holds true regardless of bundle branch pattern or other
morphology criteria.
Wellens HJ, Bar FW, Lie KI. The value of the electrocardiogram in the differential diagnosis of a tachycardia with a widened QRS complex.
Am J Med 1978;64:27–33

12. Morphology criteria  Wellens built on the observation of
Sandler and Mariott that –
Mono- or biphasic V1 QRS morphologies in a RBBB WCT
suggests VT.
Though the original paper found a 97 % PPV for this statement, later study
has been unable to confirm this; finding a PPV of only 82–83 %.
If the V1 QRS is triphasic, Wellens’ criteria suggests investigation
of V6 for an R:S ratio <1 (that is, R wave smaller than S wave)
VT.
This criterion had a modest 90 % PPV both in the original data and
subsequent evaluation
Wellens HJ, Bar FW, Lie KI. The value of the electrocardiogram in the differential diagnosis of a tachycardia with a widened QRS complex.
Am J Med 1978;64:27–33

13. ‘Rabbit ears’ Rsr’ = VT.
Wellens noted that an unusual triphasic V1, with the left R wave
taller than the right, and the S wave not crossing the baseline,
was invariably associated with VT
subsequent study has confirmed this 100 % PPV.
Wellens HJ, Bar FW, Lie KI. The value of the electrocardiogram in the differential diagnosis of a tachycardia with a widened QRS complex.
Am J Med 1978;64:27–33

15. The Kindwall Criteria of Left Bundle Branch Block
V1 or V2 with initial R >30 ms = VT.
V1 or V2 QRS onset to nadir of S wave >60 ms = VT.
V1 or V2 with notching on the S wave downstroke = VT.
Any Q in V6 = VT.
Kindwall KE, Brown J, Josephson ME. Electrocardiographic criteria for ventricular tachycardia in wide complex left bundle branch block
morphology tachycardias. Am J Cardiol 1988;61:1279–83

16. Brugada criteria algorithm
Brugada et al prospectively analyzed 384 patients with VT and
170 patients with SVT with aberrant conduction to see if it was
possible to come up with a simple criteria to help differentiate
between the two with high sensitivity and specificity
Brugada P, Brugada J, Mont L, et al. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation
1991;83:1649–59

17. The Brugada criteria algorithm involves 4 sequential
questions. If at any point, the answer is YES, then it is
VT
Brugada P, Brugada J, Mont L, et al. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation
1991;83:1649–59

18. 1. Is there an absence of an RS complex in all
precordial leads?
Yes = VT (Sensitivity 0.21, specificity 1.0)
No = Next question

19. 2. Is the R to S interval >100 msec (2.5 small boxes) in
one precordial lead?
Yes = VT (Sensitivity 0.66, specificity 0.98)
No = Next question

20. 3. Is there atrioventricular (AV) dissociation?
Yes = VT (Sensitivity 0.82, specificity 0.98)
No = Next Question

21. 4. Is there morphology criteria for VT present in
precordial leads V1/V2 and V6?
Yes = VT (Sensitivity 0.987, specificity 0.965)
No = SVT with Aberrant Conduction (Sensitivity 0.965, specificity
0.987)
Determine if a LBBB morphology (dominant S wave in V1) or a
RBBB morphology (dominant R wave in V1) then use the
appropriate section below to help differentiate.

22. 4a. LBBB Morphology: Dominant S Wave in V1 or V2
Lead V1 morphology consistent with VT:
R wave > 30 msec (PPV 0.96)
RS interval > 60 msec (PPV 0.96), as measured from R wave
onset to S wave nadir
Notched S Wave (Josephson’s Sign)

23. Lead V6 morphology consistent with VT:
QS complex (PPV 1.0)
qR wave (PPV 1.0)

24. 4b. RBBB Morphology: Dominant R Wave in V1 or V2
Lead V1 morphology consistent with VT:
Smooth, monophasic R wave (PPV 0.78)
Notched downslope to R wave (PPV 0.90)
qR wave (PPV 0.95)

25. Lead V6 morphology consistent with VT:
QS complex (PPV 1.0)
R/S Ratio < 1 (PPV 0.87)

26. Brugada algorithm

28. The Vereckei Criteria of Augmented Vector
Right (aVR)
Step 1: An initial, dominant R in aVR = VT.
Step 2: An initial, non-dominant q or r in aVR >40 ms = VT.
Step 3: Notching on an initial downstroke in aVR = VT.
Step 4: Vt≥Vi in aVR = VT
Vereckei A, Duray G, Szenasi G, et al. New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia.
Heart Rhythm 2008;5:89–9

30. The Pava Criteria of Lead II
The R wave peak time in lead II, with the interval from QRS onset
to first change in polarity (R or S peak) in lead II ≥50 ms denoting
VT
Pava LF, Perafan P, Badiel M, et al. R-wave peak time at DII: a new criterion for differentiating between wide complex QRS tachycardias.
Heart Rhythm 2010;7:922–6

31. “R/S ratio in V6 rule”
R/S ratio in RBB type wide QRS tachycrdia less than one,
favours VT
Sensitivity-0.73
Specificity-0.79
Positive predictive value 0.9

32. Josephson’s sign
Notching near the nadir of the S-wave
Suggest VT

33. Rabbit’s ear

35. Predictive Values and Accuracies of the Most Common Ventricular
Tachycardia Criteria

38. Summary

39. Factor
VT SVT with Aberrancy
Age >50 <35
History MI, CHF, CABG, MVR MVR, WPW
Cannon A Waves Present Absent
Arterial Pulse Variation No variation
First heart sound Variable Not variable
Fusion Beats Present Absent
AV dissociation Present Absent
QRS >0.14sec <0.14sec
Axis Extreme LAD (< -30) Normal or slightly abnl
Vagal Maneuvers No response Slows or terminates
QRS morphology
(RBBB-like pattern)
V1 - R or qR
V6 - rS
V1 - rsR'
V6 - R(slurredS)
QRS morphology
(LBBB-like pattern)
V1 or V2 - Broad R wave
(>40msec)
V6 - Any Q or QS
V1 - rS or QS
V6 - qRs

40. Thank you….