Approach to the Wide Complex Tachycardia: Difference between revisions

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Approach to the Wide Complex Tachycardia (view source)

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Bij een breedcomplextachycardie (hartslag > 100/min, QRS breder dan 0.12 seconde) is er het belangrijk een onderscheid te maken tussen een supraventriculaire tachycardie met aberante geleiding en een ventrikeltachycardie. Er zijn meerdere algoritmes om dit onderscheid te maken.  
During wide complex tachycardia (heart rate > 100/min, QRS > 0.12 sec) the differentiation between supraventricular and ventricular origin of the arrhythmia is important to guide therapy. Several algorithms have been developed to aid in this differentiation (below). It is important to keep in mind that a good estimate of VT ''versus'' SVT can be made based on the clinical vignette:
== The ACC algorhythm <cite>ACC</cite>==
* 'Horizontal entrance' into the ER. Older patient with previous myocardial infarction = most likely VT
[[File:VT_algorythm_en.png|800px|thumb|left|SVT vs VT algorhytm. Adapted from <cite>ACC</cite>]]
* Younger patient with known paroxysmal tachycardias and who is hemodynamically stable = most like SVT
== The ACC algorithm <cite>ACC</cite>==
[[File:VT_algorithm_en.svg|800px|thumb|left|SVT vs VT algorhytm. Adapted from <cite>ACC</cite>]]
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== Brugada criteria ter onderscheiding van breedcomplextachycardiën ==
==ECG algorithms to differentiate wide QRS-complex tachycardias==
Several ECG algorithms have been developed to differentiate wide QRS-complex tachycardias. Most of them performed very well in the population they were based upon. A recent review tested five commonly used algorithms in a control population and found that each of them only performed reasonably well in differentiating VT from SVT (accuracy 66-77%).<cite>Jastrzekbsi</cite> The five criteria tested were:
* Brugada algorithm (below).<cite>Brug1</cite> This is the most commonly used algorithm. SN 89%, SP 59.2%.
* The lead II R-wave-peak-time (below). <cite>Brugada2</cite> Sensitivity 60%, specificity 82.7%.
* The aVR algorithm (below). <cite>Vereckei</cite> Sensitivity 87.1%, specificity 48%.
* The Bayesian algorithm.<cite>Lau</cite> This calculates a score based on 19 morpologic features. Sensitivity 89%, specificity 52%.
* The Griffith algorithm (below).<cite>Griffith</cite> Sensitivity 94.2%, specificity 39.8%.
== Brugada algorithm ==
[[File:Brugada_algorithm.svg|500px|thumb|left]]
 
{| class="wikitable" width="500px"
{| class="wikitable" width="500px"
! colspan="3" |Brugada criteria ter differentiatie van [[supraventriculaire ritmestoornissen]] (SVT's) van [[ventriculaire ritmestoornissen]] (VT's)<cite>Brug1</cite>
! colspan="3" | Morphological criteria (if the above criteria are inconclusive)
|-
| Zijn er fusie of capture beats? (dit item komt niet uit de Brugada criteria, maar is wel heel specifiek)|| Ja? => VT || specificiteit=100% [[image:fusionbeat.png|thumb|100px]]
|-
| RS complexen afwezig over de voorwand? || Ja? => [[VT]] || sensitiviteit=21% specifiteit=100%
|-
| RS-interval in één van de precordiale afleidingen > 100 msec (bij patient zonder anti-arritmetica)? || Ja? => VT || sensitiviteit=66% specifiteit=98%
|-
| Is er [[AV-dissociatie]]? || Ja? => waarschijnlijk [[VT]] (NB [[AVNRT|AV nodale re-entry]] kan ook AV-dissociatie geven!)|| sensitiviteit=82% specifiteit=98%
|-
|-
! colspan="3" | Morfologische criteria (als bovenstaande criteria geen uitkomst bieden)
!colspan="3" |[[LBBB]] pattern
|-
|-
!colspan="3" |[[LBTB]] patroon
| Initial R more than 40ms? ||Yes => VT || [[Image:Rhythm_RSratio.png|thumb|100px]]
|-
|-
| Initiële R breder dan 40ms? ||Ja => VT || [[Afbeelding:Rhythm_RSratio.png|thumb|100px]]
| Slurred or notched downwards leg of S wave in leads V1 or V2 || Yes => [[VT]] ||
|-
|-
| Slurred of notched neergaand been van S golf in afleiding V1 of V2 || Ja => [[VT]] ||
| Beginning of Q to nadir QS >60 ms in V1 or V2? || Yes => [[VT]] || LR >50:1
|-
|-
| Begin Q tot nadir QS >60 ms in V1 of V2? || Ja => [[VT]] || LR >50:1
| Q or QS in V6? || Yes => [[VT]] || LR >50:1
|-
|-
| Q of QS in V6? || Ja => [[VT]] || LR >50:1
| colspan="3" |[[Image:Rhythm_LBTBmorph_nl.png|thumb|300px]]
|-
|-
| colspan="3" |[[Afbeelding:Rhythm_LBTBmorph_nl.png|thumb|300px]]
! colspan="3" |[[RBBB]] pattern
|-
|-
! colspan="3" |[[RBTB]] patroon
| Monofasic R or qR in V1? ||Yes => [[VT]] ||
|-
|-
| Monofasische R of qR in V1? ||Ja => [[VT]] ||
| R taller than R' (rabbit-ear sign)?||Yes => [[VT]] || LR >50:1
|-
|-
| R hoger dan R' (rabbit-ear sign)?|| Ja => [[VT]] || LR >50:1
| rS in V6? || Yes => VT || LR >50:1
|-
|-
| rS in V6? || Ja => VT || LR >50:1
| colspan="3" |[[Image:Rhythm_RBTBmorph_nl.png|thumb|300px]]
|-
| colspan="3" |[[Afbeelding:Rhythm_RBTBmorph_nl.png|thumb|300px]]
|-
|-
|}
|}
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==Voorbeelden==
 
== Ultrasimple Brugada criterion: RW to peak Time (RWPT)  ==
[[File:RWPT.svg|thumb|right|300px|R-wave to Peak Time ≥ 50ms in lead II strongly suggests VT]]In 2010 Joseph Brugada et al. published a new criterion to differentiate VT from SVT in wide complex tachycardias: the R wave peak time in Lead II <cite>Brugada2</cite>. They suggest measuring the duration of onset of the QRS to the first change in polarity (either nadir Q or peak R) in lead II. If the RWPT is ≥ 50ms the likelihood of a VT very high (positive likelihood ratio 34.8). This criterion was successful in their own population of 163 selected patients and is awaiting prospective testing in a larger trial.
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== Vereckei aVR algorithm <cite>Vereckei</cite>==
[[File:Vereckei_algorithm.png|500px|thumb|left]]
[[File:vivt.png|300px|thumb|If the distance traveled on the Y axis in the initial 40ms of the QRS complex is smaller than that traveled in the terminal 40ms of the QRS complex, a VT is much more likely]]
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== Griffith (Bundle Branch Block) algorithm ==
The Griffith algorithm <cite>Griffith</cite>reverses the diagnostic strategy:  unless simple rules for a positive diagnosis of supraventricular tachycardia are satisfied, ventricular tachycardia is diagnosed by default. The algorithm only looks at bundle brach block morphology. Supraventricular tachycardia is diagnoses when ECG findings match typical bundle branch block:
* LBBB: rS or QS wave in leads V1 and V2, delay to S wave nadir < 70 ms, and R wave and no Q wave in lead V6
* RBBB: rSR' wave in lead V1 and an RS wave in lead V6, with R wave height greater than S wave depth
 
==Examples==
<gallery>
<gallery>
Image:wide_qrs_tachy_AAM1.jpg|Breedcomplextachycardie. Geen AV dissociatie. RBTB. Lijkt op complex bij SR van zelfde patient. Conclusie: [[SVT met aberrantie]]
Image:wide_qrs_tachy_AAM1.jpg|Wide complex tachycardia. No AV dissociation. RBBB. Resembles sinus rhythm from the same patient. Conclusion: SVT with [[RBBB]]
Image:wide_qrs_tachy_AAM2.jpg|ECG van zelfde patient als eerste voorbeeld, maar nu in [[sinusritme]]. Het QRS complex is nauwelijks gewijzigd
Image:wide_qrs_tachy_AAM2.jpg|ECG from the same patient in sinus rhythm. The QRS complex is very similiar.
Image:wide_qrs_tachy_AAM3.png|Breedcomplextachycardie. LBTB configuratie. Afwezigheid RS over voorwand. [[AV-dissociatie]]: de pijlen wijzen de p-toppen aan. Conclusie: [[ventrikeltachycardie]]
Image:wide_qrs_tachy_AAM3.png|Wide complex tachycardia. LBBB configuration. Absence of RS in the chest leads. [[AV dissociation]] is present. Conclusion: [[VT]]
Image:wide_qrs_tachy_AAM4.png|Breedcomplextachycardie. [[LBTB]] configuratie. Afwezigheid RS over vorwand. [[AV-dissociatie]]: de pijlen wijzen de p-toppen aan. Conclusie: [[ventrikeltachycardie]]
Image:wide_qrs_tachy_AAM4.png|Wide complex tachycardia. LBBB configuration. Absence of RS in the chest leads. [[AV dissociation]] is present. Conclusion: [[VT]]
</gallery>
</gallery>
== Referenties ==
== Referenties ==
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#ACC pmid=14563598
#ACC pmid=14563598
#Brug1 pmid=2022022
#Brug1 pmid=2022022
#Vereckei pmid=17272358
#Brugada2 pmid=20215043
#Jastrzekbsi pmid=22333239
#Lau pmid=11060873
#Griffith pmid=7905552
</biblio>
</biblio>
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