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APPROACH TO WIDE QRS COMPLEX TACHYCARDIA

Dr HA TUAN KHANH Dr DAVID TRAN. APPROACH TO WIDE QRS COMPLEX TACHYCARDIA. Content. Definition Causes of WCT Diagnosis criteria Clinical history Physical examination ECG criteria: Brugada criteria, other criteria, findings favoring SVT, VT vs AVRT criteria Management Unstable hemodynamic

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APPROACH TO WIDE QRS COMPLEX TACHYCARDIA

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  1. Dr HA TUAN KHANH Dr DAVID TRAN APPROACH TO WIDE QRS COMPLEX TACHYCARDIA

  2. Content • Definition • Causes of WCT • Diagnosis criteria • Clinical history • Physical examination • ECG criteria: Brugada criteria, other criteria, findings favoring SVT, VT vs AVRT criteria • Management • Unstable hemodynamic • Stable hemodynamic

  3. Definition Wide QRS complex tachycardia is a rhythm with a rate of more than 100 b/m and QRS duration of more than 120 ms SVT (20%) VT (80%) Stewart RB. Ann Intern Med 1986

  4. Causes of wide QRS complex tachycardia • Supraventricular tachycardia - with prexsisting BBB - with BBB due to heart rate (aberrant conduction) - antidromic tachycardia in WPW syndrome • Ventricular tachycardia

  5. SVT vs VT Clinical history

  6. SVT vs VTPhysical examination • Physical findings that indicate presence of AV dissociation (cannon A waves, variable-intensity S1,variation in BP unrelated to respiration) if present are useful • Termination of WCT in response to maneuvers like Valsalva, carotid sinus pressure, or adenosine is strongly in-favor of SVT but there are well-documented cases of VT responsive to these

  7. SVT vs VT

  8. SVT vs VTECG criteria: Brugada algorithm Brugada P. Ciculation 1991

  9. Step 1

  10. Step 2

  11. Step 3

  12. Step 4: LBBB - type wide QRS complex VT SVT R wave >40ms notching of S wave small R wave V1 fast downslope of S wave > 70ms Q wave V6 no Q wave

  13. Step 4: RBBB - type wide QRS complex VT SVT qR (or Rs) complex monophasic R wave rSR’ configuration V1 or R/S > 1 R/S ratio < 1 QS complex V6 or

  14. Step 4: RBBB morphology

  15. Step 4: LBBB morphology

  16. Other ECG criteria • North - west QRS axis deviation • Negative or positive concordance • Fusion beats, capture beats • Ventriculoatrial conduction with block • RBBB morphology with LAD > - 300 • LBBB morphology with RAD > + 900 • Previous ECG show MI or previous ECG show that during sinus rhythm, bifascular block is present, which changes in configuration during tachycardia

  17. Concordance and Northwest Axis

  18. Fusion beat and capture beat

  19. Ventriculoatrial conduction with block

  20. RBBB morphology with LAD

  21. LBBB morphology with RAD

  22. Previous MI

  23. Previous LBBB

  24. Findings favoring SVT • Triphasic pattern in V1 and V6 • Rabbit’s ear • Previous ECG: Preexistent BBB or preexcitation

  25. Triphasic pattern

  26. Rabbit’s ear

  27. Wide complex SVT from preexisting RBBB

  28. Wide complex SVT from preexisting LBBB

  29. VT vs AVRTECG criteria Brugada P. Ciculation 1991

  30. Wide complex SVT from bypass tract

  31. Summary : diagnosis evaluation ACC/AHA/ESC guidelines for management of pt with SVT. Circulation 2003

  32. Management – Hemodynamic compromise • Unstable patient, but still responsible with a discernible BP and/or pulse: - Emergent synchronized cardioversion - If the QRS complex and T wave cannot be distinguished accurately → immediate defibrillation • Unstable patient, unresponsive or pulseless → standard ACLS resusciation algorithms

  33. ACLS pulseless arrest algorithm AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Ciurculation 2005

  34. Management – Stable hemodynamic • VT or WCT of uncertain etiology: • Any associated conditions (cardiac ischemia, heart failure, electrolyte abnormalities or drug toxicities) • Class I and III antiarrhythmic drugs - Amiodarone: 150mg IV/10mins followed by an infusion of 1mg/min for 6 hours, then 0,5mg/min - Procainamide: 15-18mg/kg infusion over 25-30mins, followed by 1-4mg/min by continuous infusion - Lidocaine: 1-1,5mg/kg IV/2-3mins followed by an infusion of 1-4mg/min • Urgent or elective cardioversion

  35. Management – Stable hemodynamic • SVT • Vagal maneuvers: carotid sinus pressure (if no carotid bruits) or Valsava maneuver • Adenosine: 6mg over 1-2 seconds. If the initial dose is ineffective, a 12mg dose may be given and repeated once if necessary • Calcium channel blocker (Verapamil 2.5 to 5mg IV) or beta blokers (Metoprolol 5 to 10 mg IV) • Cardioversion

  36. Acute management hemodynamically stable and regular tachycardia ACC/AHA/ESC guidelines for management of pt with SVT. Circulation 2003

  37. Recommendation acute management hemodynamically stable and regular tachycardia ACC/AHA/ESC guidelines for management of pt with SVT. Circulation 2003

  38. Tachycardia algorithm AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Ciurculation 2005

  39. Tachycardia algorithm

  40. Thank you for your attention

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