APPROACH TO WIDE QRS COMPLEX TACHYCARDIA Dr HA TUAN KHANH Dr DAVID TRAN.
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Transcript of APPROACH TO WIDE QRS COMPLEX TACHYCARDIA Dr HA TUAN KHANH Dr DAVID TRAN.
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APPROACH TO WIDE QRS COMPLEX APPROACH TO WIDE QRS COMPLEX TACHYCARDIATACHYCARDIA
Dr HA TUAN KHANHDr HA TUAN KHANH
Dr DAVID TRANDr DAVID TRAN
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ContentContent
1. Definition
2. Causes of WCT
3. Diagnosis criteria Clinical history Physical examination ECG criteria: Brugada criteria, other criteria, findings favoring
SVT, VT vs AVRT criteria
4. Management Unstable hemodynamic Stable hemodynamic
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DefinitionDefinition
Wide QRS complex tachycardia is a rhythm with a rate of more than
100 b/m and QRS duration of more than 120 ms
VT (80%)
SVT (20%)
Stewart RB. Ann Intern Med 1986
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• Supraventricular tachycardia
- with prexsisting BBB
- with BBB due to heart rate (aberrant conduction)
- antidromic tachycardia in WPW syndrome
• Ventricular tachycardia
Causes of wide QRS complex tachycardia
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SVT vs VT Clinical history
Medication Drug-induced tachycardia → Torsade de pointes
Diuretics
Digoxin-induced arrhythmia → [digoxin] ≥2ng/l or normal if hypokalemia
Age - ≥ 35 ys → VT (positive predictive value of 85%)
Underlying heart disease Previous MI → 98% VT
Pacemakers or ICD Increased risk of ventricular tachyarrhythmia
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SVT vs VTSVT vs VTPhysical examination Physical 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
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SVT vs VTECG criteria: Brugada algorithm
Brugada P. Ciculation 1991
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Step 1
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Step 2
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Step 3
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Step 4: LBBB - type wide QRS complex
SVT VT
small R wave notching of S waveR wave >40ms
fast downslopeof S wave
no Q wave
Q wave
> 70ms
V1
V6
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Step 4: RBBB - type wide QRS complex
SVT VT
V1
V6
or
or
R/S > 1 R/S ratio < 1 QS complex
rSR’ configuration monophasic R wave qR (or Rs) complex
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Step 4: RBBB morphology
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Step 4: LBBB morphology
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Other ECG criteriaOther 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
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Concordance and Northwest Axis
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Fusion beat and capture beat
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Ventriculoatrial conduction with block
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RBBB morphology with LAD
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LBBB morphology with RAD
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Previous MI
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Previous LBBB
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Findings favoring SVTFindings favoring SVT
• Triphasic pattern in V1 and V6• Rabbit’s ear• Previous ECG: Preexistent BBB or preexcitation
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Triphasic patternTriphasic pattern
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Rabbit’s earRabbit’s ear
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Wide complex SVT from preexisting RBBBWide complex SVT from preexisting RBBB
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Wide complex SVT from preexisting LBBBWide complex SVT from preexisting LBBB
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VT vs AVRTVT vs AVRTECG criteriaECG criteria
Brugada P. Ciculation 1991
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Wide complex SVT from bypass tractWide complex SVT from bypass tract
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Summary : diagnosis evaluationSummary : diagnosis evaluation
ACC/AHA/ESC guidelines for management of pt with SVT. Circulation 2003
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Management – Hemodynamic compromiseManagement – Hemodynamic compromise
1. 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
2. Unstable patient, unresponsive or pulseless → standard ACLS resusciation algorithms
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ACLS pulseless arrest algorithmACLS pulseless arrest algorithm
AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Ciurculation 2005
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Management – Stable hemodynamicManagement – Stable hemodynamic
1. 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
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Management – Stable hemodynamicManagement – Stable hemodynamic
2. 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
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Acute management hemodynamically stable and regular tachycardiaAcute management hemodynamically stable and regular tachycardia
ACC/AHA/ESC guidelines for management of pt with SVT. Circulation 2003
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Recommendation acute management hemodynamically stable Recommendation acute management hemodynamically stable and regular tachycardiaand regular tachycardia
ACC/AHA/ESC guidelines for management of pt with SVT. Circulation 2003
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Tachycardia algorithmTachycardia algorithm
AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Ciurculation 2005
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Tachycardia algorithmTachycardia algorithm
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Thank you for your attentionThank you for your attention