Approach to the Wide Complex Tachycardia: Difference between revisions

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== Brugada criteria ==
== Brugada criteria ==
{| 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" |Brugada criteria to differentiate [[SVT]] from [[VT]] <cite>Brug1</cite>
|-
|-
| 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]]
| Are there fusion or capture beats? (this is not an item from Brugada, it is however very specific|| Yes? => VT || specificy=100% [[image:fusionbeat.png|thumb|100px]]
|-
|-
| RS complexen afwezig over de voorwand? || Ja? => [[VT]] || sensitiviteit=21% specifiteit=100%
| RS complexen missing in the chest leads? || Yes? => [[VT]] || sensitivity=21% specificity=100%
|-  
|-  
| RS-interval in één van de precordiale afleidingen > 100 msec (bij patient zonder anti-arritmetica)? || Ja? => VT || sensitiviteit=66% specifiteit=98%
| RS-interval in one of the cheast leads > 100 msec (in the absence of anti-arrhythmics)? || Yes? => VT || sensitivity=66% specificity=98%
|-
|-
| Is er [[AV-dissociatie]]? || Ja? => waarschijnlijk [[VT]] (NB [[AVNRT|AV nodale re-entry]] kan ook AV-dissociatie geven!)|| sensitiviteit=82% specifiteit=98%
| [[AV-dissociation]]? || Yes? => probably [[VT]] (Note [[AVNRT]] can also present with AV dissociation!)|| sensitivity=82% specifity=98%
|-
|-
! colspan="3" | Morfologische criteria (als bovenstaande criteria geen uitkomst bieden)
! colspan="3" | Morphological criteria (if the above criteria are inconclusive)
|-
|-
!colspan="3" |[[LBTB]] patroon
!colspan="3" |[[LBBB]] pattern
|-
|-
| Initiële R breder dan 40ms? ||Ja => VT || [[Image:Rhythm_RSratio.png|thumb|100px]]
| Initial R more than 40ms? ||Yes => VT || [[Image:Rhythm_RSratio.png|thumb|100px]]
|-
|-
| Slurred of notched neergaand been van S golf in afleiding V1 of V2 || Ja => [[VT]] ||
| Slurred or notched downwards leg of S wave in leads V1 or V2 || Yes => [[VT]] ||
|-
|-
| Begin Q tot nadir QS >60 ms in V1 of V2? || Ja => [[VT]] || LR >50:1
| Beginning of Q to nadir QS >60 ms in V1 or V2? || Yes => [[VT]] || LR >50:1
|-
|-
| Q of QS in V6? || Ja => [[VT]] || LR >50:1
| Q or QS in V6? || Yes => [[VT]] || LR >50:1
|-
|-
| colspan="3" |[[Image:Rhythm_LBTBmorph_en.png|thumb|300px]]
| colspan="3" |[[Image:Rhythm_LBTBmorph_en.png|thumb|300px]]
|-
|-
! colspan="3" |[[RBTB]] patroon
! colspan="3" |[[RBBB]] pattern
|-
|-
| Monofasische R of qR in V1? ||Ja => [[VT]] ||
| Monofasic R or qR in V1? ||Yes => [[VT]] ||
|-
|-
| R hoger dan R' (rabbit-ear sign)?|| Ja => [[VT]] || LR >50:1
| R taller than R' (rabbit-ear sign)?||Yes => [[VT]] || LR >50:1
|-
|-
| rS in V6? || Ja => VT || LR >50:1
| rS in V6? || Yes => VT || LR >50:1
|-
|-
| colspan="3" |[[Image:Rhythm_RBTBmorph_en.png|thumb|300px]]
| colspan="3" |[[Image:Rhythm_RBTBmorph_en.png|thumb|300px]]
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{{clr}}
{{clr}}


==Voorbeelden==
==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. Conclusio  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]]`ß
</gallery>
</gallery>
== Referenties ==
== Referenties ==

Revision as of 14:05, 11 November 2009

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 algorhythms have been developed to aid in this differentiation.

The ACC algorhythm [1]

SVT vs VT algorhytm. Adapted from [1]


Brugada criteria

Brugada criteria to differentiate SVT from VT [2]
Are there fusion or capture beats? (this is not an item from Brugada, it is however very specific Yes? => VT specificy=100%
Fusionbeat.png
RS complexen missing in the chest leads? Yes? => VT sensitivity=21% specificity=100%
RS-interval in one of the cheast leads > 100 msec (in the absence of anti-arrhythmics)? Yes? => VT sensitivity=66% specificity=98%
AV-dissociation? Yes? => probably VT (Note AVNRT can also present with AV dissociation!) sensitivity=82% specifity=98%
Morphological criteria (if the above criteria are inconclusive)
LBBB pattern
Initial R more than 40ms? Yes => VT
Rhythm RSratio.png
Slurred or notched downwards leg of S wave in leads V1 or V2 Yes => VT
Beginning of Q to nadir QS >60 ms in V1 or V2? Yes => VT LR >50:1
Q or QS in V6? Yes => VT LR >50:1
File:Rhythm LBTBmorph en.png
RBBB pattern
Monofasic R or qR in V1? Yes => VT
R taller than R' (rabbit-ear sign)? Yes => VT LR >50:1
rS in V6? Yes => VT LR >50:1
File:Rhythm RBTBmorph en.png


Examples

  • Wide complex tachycardia. No AV dissociation. RBBB. Resembles sinus rhythm from the same patient. Conclusio SVT with RBBB

    Wide complex tachycardia. No AV dissociation. RBBB. Resembles sinus rhythm from the same patient. Conclusio SVT with RBBB

  • ECG from the same patient in sinus rhythm. The QRS complex is very similiar.

    ECG from the same patient in sinus rhythm. The QRS complex is very similiar.

  • Wide complex tachycardia. LBBB configuration. Absence of RS in the chest leads. AV dissociation is present. Conclusion: VT

    Wide complex tachycardia. LBBB configuration. Absence of RS in the chest leads. AV dissociation is present. Conclusion: VT

  • Wide complex tachycardia. LBBB configuration. Absence of RS in the chest leads. AV dissociation is present. Conclusion: VT`ß

    Wide complex tachycardia. LBBB configuration. Absence of RS in the chest leads. AV dissociation is present. Conclusion: VT`ß

Referenties

  1. Blomström-Lundqvist C, Scheinman MM, Aliot EM, Alpert JS, Calkins H, Camm AJ, Campbell WB, Haines DE, Kuck KH, Lerman BB, Miller DD, Shaeffer CW, Stevenson WG, Tomaselli GF, Antman EM, Smith SC Jr, Alpert JS, Faxon DP, Fuster V, Gibbons RJ, Gregoratos G, Hiratzka LF, Hunt SA, Jacobs AK, Russell RO Jr, Priori SG, Blanc JJ, Budaj A, Burgos EF, Cowie M, Deckers JW, Garcia MA, Klein WW, Lekakis J, Lindahl B, Mazzotta G, Morais JC, Oto A, Smiseth O, Trappe HJ, and European Society of Cardiology Committee, NASPE-Heart Rhythm Society. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias--executive summary. a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) developed in collaboration with NASPE-Heart Rhythm Society. J Am Coll Cardiol. 2003 Oct 15;42(8):1493-531. DOI:10.1016/j.jacc.2003.08.013 | PubMed ID:14563598 | HubMed [ACC]
  2. Brugada P, Brugada J, Mont L, Smeets J, and Andries EW. A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex. Circulation. 1991 May;83(5):1649-59. DOI:10.1161/01.cir.83.5.1649 | PubMed ID:2022022 | HubMed [Brug1]

All Medline abstracts: PubMed | HubMed

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