svt

versus
svt with aberrancy
 Medication given
for the treatment
of a
supraventricular
tachycardia (SVT)
may be harmful
to a patient with
a ventricular
tachycardia (VT)

cular tachycardia: diagnosis of broad QRS complex tachycardia, Wellens, Heart 2001;86:57958
Features that favour VT
Absence of typical RBBB or LBBB morphology
Extreme axis deviation (northwest axis) QRS is positive in aVR and negative in I + aVF.
Very broad complexes (>160ms)
AV dissociation(P and QRS complexes at different rates)
Capturebeats occur when the sinoatrial node transiently captures the ventricles, in the
midst of AV dissociation, to produce a QRS complex of normal duration.
Fusionbeats occur when a sinus and ventricular beat coincides to produce a hybrid
complex.
Positive or negativeconcordancethroughout the chest leads, i.e. leads V1-6 show entirely
positive (R) or entirely negative (QS) complexes, with no RS complexes seen.
Brugadas sign The distance from the onset of the QRS complex to the nadir of the S-wave
is > 100ms
Josephsons sign Notching near the nadir of the S-wave
RSR complexes with ataller leftrabbit ear. This is the most specific finding in favour of VT.
This is in contrast to RBBB, where the right rabbit ear is taller.
AV dissociation
Capturebeats

Fusionbeats
 Brugadas sign (red
callipers) and Josephsons
sign (blue arrow)

Taller left rabbit ear in VT

Taller right rabbit ear in RBBB

et al.A new approach to the differential diagnosis of a regular tachycardia with a wide QRS complex.Circu
1. Absence of an RS complex in
all precordial leads
This is essentially the same as
havingpositiveornegative concordance.
If all the precordial leads consist of either monophasic R
or S waves then VT is diagnosed.
If there are any RS complexes present in V1-6 > move
on to the next step of the algorithm
 Precordial S waves only -> VT

RS complexes present > go to step 2

. RS interval > 100ms in one precordial lead

If RS complexes are present in

V1-6 then the RS interval is
measured.
This is the time from the onset
of the R wave to the nadir of
the S wave.
If the RS interval is > 100 ms
> VT is diagnosed.
If the RS interval is < 100 ms
> move on to step 3.
3. AV dissociation
The ECG is scrutinised for hidden P waves; these are
often superimposed on the QRS complexes and may be
difficult to see.
If P waves are present at a different rate to the QRS
complexes > AV dissociation is present and VT is
diagnosed.
If no evidence of AV dissociation can be seen > go to
step 4.
4. Morphological Criteria for VT
If there is a dominant R wave in V1 > see criteria for
RBBB-like morphology.
If there is a dominant S wave in V1 > see criteria for
LBBB-like morphology.
RBBB pattern
Appearance in V1-2
Smooth monophasic R wave
Notched downslope to the R wave the taller left rabbit ear
(= Marriotts sign)
A qR complex (small Q wave, tall R wave) in V1
RBBB pattern
Appearance in V6
QS complex a completely negative complex with no
R wave (= strongly suggestive of VT).
R/S ratio < 1 small R wave, deep S wave (indicates
VT only ifLADis also present)
LBBB pattern
V1-V2
Initial R wave > 30-40 ms duration.
Notching or slurring of the S wave
(Josephsons sign).
RS interval (time from R wave onset to
S wave nadir) > 60-70 ms
 V6
QS wavesin V6 (as with RBBB-like patterns, this finding is
very specific for VT).
qR pattern= small Q wave, large R wave
Vereckei aVR algorithm

Vereckei A,.Application of a new

algorithm in the differential diagnosis
of wide QRS complex tachycardia.Eur
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