Approach to the diagnosis and treatment of wide QRS complex tachycardias
- Philip J Podrid, MD, FACC
Philip J Podrid, MD, FACC
- Professor of Medicine, Professor of Pharmacology and Experimental Therapeutics
- Boston University School of Medicine
- Lecturer, Harvard Medical School
- Leonard I Ganz, MD, FHRS, FACC
Leonard I Ganz, MD, FHRS, FACC
- Section Editor — Cardiac Arrhythmias
- Director of Cardiac Electrophysiology
- Heritage Valley Health System
- Section Editors
- Peter J Zimetbaum, MD
Peter J Zimetbaum, MD
- Section Editor — Cardiac Arrhythmias
- Associate Professor of Medicine
- Harvard Medical School
- Ary L Goldberger, MD
Ary L Goldberger, MD
- Section Editor — Electrocardiography
- Professor of Medicine
- Harvard Medical School
- James Hoekstra, MD
James Hoekstra, MD
- Section Editor — Adult Cardiology Emergencies
- Professor and Fredrick Glass Chair
- Wake Forest University
Tachycardias are broadly categorized based upon the width of the QRS complex on the electrocardiogram (ECG).
●A narrow QRS complex (<120 msec) reflects rapid activation of the ventricles via the normal His-Purkinje system, which in turn suggests that the arrhythmia originates above or within the atrioventricular (AV) node (ie, a supraventricular tachycardia).
●A widened QRS (≥120 msec) occurs when ventricular activation is abnormally slow, most commonly because the arrhythmia originates outside of the normal conduction system (eg, ventricular tachycardia), or because of abnormalities within the His-Purkinje system (eg, supraventricular tachycardia with aberrancy). Much less common are pre-excited tachycardias; these are supraventricular tachycardias with antegrade conduction over an accessory pathway, resulting in direct activation of the ventricular myocardium, similar to the situation with a ventricular rhythm. This only occurs in a minority of patients with pre-excitations syndromes (eg, Wolff-Parkinson-White Syndrome).
A wide complex tachycardia (WCT) represents a unique clinical challenge for two reasons:
●Diagnosing the arrhythmia is difficult – Although most WCTs are due to ventricular tachycardia (VT), the differential diagnosis includes a variety of supraventricular tachycardias (SVTs). Diagnostic algorithms are complex and imperfect.
- Buxton AE, Marchlinski FE, Doherty JU, et al. Hazards of intravenous verapamil for sustained ventricular tachycardia. Am J Cardiol 1987; 59:1107.
- Stewart RB, Bardy GH, Greene HL. Wide complex tachycardia: misdiagnosis and outcome after emergent therapy. Ann Intern Med 1986; 104:766.
- Dancy M, Camm AJ, Ward D. Misdiagnosis of chronic recurrent ventricular tachycardia. Lancet 1985; 2:320.
- Akhtar M, Shenasa M, Jazayeri M, et al. Wide QRS complex tachycardia. Reappraisal of a common clinical problem. Ann Intern Med 1988; 109:905.
- European Heart Rhythm Association, Heart Rhythm Society, Zipes DP, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol 2006; 48:e247.
- Gupta AK, Thakur RK. Wide QRS complex tachycardias. Med Clin North Am 2001; 85:245.
- Tchou P, Young P, Mahmud R, et al. Useful clinical criteria for the diagnosis of ventricular tachycardia. Am J Med 1988; 84:53.
- Miller JM, Hsia HH, Rothman SA, et al. Ventricular tachycardia versus supraventricular tachycardia with aberration: electrocardiographic distinctions. In: Cardiac Electrophysiology From Cell to Bedside, Zipes DP, Jalife Jose (Eds), W.B. Saunders, Philadelphia 2000. p.696.
- Knight BP, Pelosi F, Michaud GF, et al. Physician interpretation of electrocardiographic artifact that mimics ventricular tachycardia. Am J Med 2001; 110:335.
- Morady F, Baerman JM, DiCarlo LA Jr, et al. A prevalent misconception regarding wide-complex tachycardias. JAMA 1985; 254:2790.
- Baerman JM, Morady F, DiCarlo LA Jr, de Buitleir M. Differentiation of ventricular tachycardia from supraventricular tachycardia with aberration: value of the clinical history. Ann Emerg Med 1987; 16:40.
- Ranger S, Talajic M, Lemery R, et al. Kinetics of use-dependent ventricular conduction slowing by antiarrhythmic drugs in humans. Circulation 1991; 83:1987.
- Ranger S, Talajic M, Lemery R, et al. Amplification of flecainide-induced ventricular conduction slowing by exercise. A potentially significant clinical consequence of use-dependent sodium channel blockade. Circulation 1989; 79:1000.
- Pinski SL, Trohman RG. Implantable cardioverter-defibrillators: implications for the nonelectrophysiologist. Ann Intern Med 1995; 122:770.
- Wellens HJ, Bär 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.
- Griffith MJ, de Belder MA, Linker NJ, et al. Multivariate analysis to simplify the differential diagnosis of broad complex tachycardia. Br Heart J 1991; 66:166.
- Wellens HJ. Electrophysiology: Ventricular tachycardia: diagnosis of broad QRS complex tachycardia. Heart 2001; 86:579.
- Lau EW, Pathamanathan RK, Ng GA, et al. The Bayesian approach improves the electrocardiographic diagnosis of broad complex tachycardia. Pacing Clin Electrophysiol 2000; 23:1519.
- Crijns HJ, van Gelder IC, Lie KI. Supraventricular tachycardia mimicking ventricular tachycardia during flecainide treatment. Am J Cardiol 1988; 62:1303.
- Murdock CJ, Kyles AE, Yeung-Lai-Wah JA, et al. Atrial flutter in patients treated for atrial fibrillation with propafenone. Am J Cardiol 1990; 66:755.
- Militianu A, Salacata A, Meissner MD, et al. Ventriculoatrial conduction capability and prevalence of 1:1 retrograde conduction during inducible sustained monomorphic ventricular tachycardia in 305 implantable cardioverter defibrillator recipients. Pacing Clin Electrophysiol 1997; 20:2378.
- Haley JH, Reeder GS. Images in cardiovascular Medicine. Wide-complex tachycardia. Circulation 2000; 102:E52.
- Alberca T, Almendral J, Sanz P, et al. Evaluation of the specificity of morphological electrocardiographic criteria for the differential diagnosis of wide QRS complex tachycardia in patients with intraventricular conduction defects. Circulation 1997; 96:3527.
- 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.
- Rosenbaum MB. Classification of ventricular extrasystoles according to form. J Electrocardiol 1969; 2:289.
- Swanick EJ, LaCamera F Jr, Marriott HJ. Morphologic features of right ventricular ectopic beats. Am J Cardiol 1972; 30:888.
- Gozensky C, Thorne D. Rabbit ears: an aid in distinguishing ventricular ectopy from aberration. Heart Lung 1974; 3:634.
- 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.
- Vereckei A, Duray G, Szénási G, et al. Application of a new algorithm in the differential diagnosis of wide QRS complex tachycardia. Eur Heart J 2007; 28:589.
- Isenhour JL, Craig S, Gibbs M, et al. Wide-complex tachycardia: continued evaluation of diagnostic criteria. Acad Emerg Med 2000; 7:769.
- Lau EW, Ng GA. Comparison of the performance of three diagnostic algorithms for regular broad complex tachycardia in practical application. Pacing Clin Electrophysiol 2002; 25:822.
- Diagnostic uncertainty
- CAUSES OF WCT
- Ventricular tachycardia
- Supraventricular tachycardia
- Artifact mimicking VT
- GENERAL APPROACH
- Assessment of stability
- Physical examination
- - Carotid sinus pressure
- - Pharmacologic interventions
- Additional tests
- EVALUATION OF THE ELECTROCARDIOGRAM
- Basic features
- AV dissociation
- - Dissociated P waves
- - Fusion beats
- - Capture beats
- QRS morphology
- - Diagnostic criteria
- - Variation in QRS and ST-T shape
- ALGORITHMS FOR WCT DIAGNOSIS
- Brugada criteria
- Alternative approaches
- VT versus AVRT
- Algorithm performance
- Unstable patient
- Stable patient
- - Ventricular tachycardia
- - Supraventricular tachycardia
- Recurrent or refractory WCT
- Presence of a pacemaker
- Presence of an ICD
- - Disabling an ICD
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS
- Assessment of patient stability
- Diagnostic evaluation
- - Diagnosis of VT
- - Diagnosis of SVT
- - Uncertain diagnosis
- - Ventricular tachycardias
- - Supraventricular tachycardias