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.
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- 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