Principles of ECG Diagnosis

4
ventricular arrhythmias
Dr Ghazi Radaideh
MD, FRCP
Rashid Hospital
Dubai - UAE

ECG Diag 4/ghazi

Reading 12-Lead ECG step-by-step

(RAWIHI)
1. Rate, Rhythm and Regularity
2. Determine the QRS Axis
3. Evaluate the Waves (P,QRS,T ),
Intervals (PR,ST,QT)
4. Evaluate for chamber Hypertrophy
5. Look for myocardial Infarction and Ischemia
6. Interpret the ECG

ECG Diag 4/ghazi

Ventricular Arrhythmias
1. Premature ventricular complexes (PVCs)
2. Idioventricular rhythm &Accelerated
ventricular rhythms
3. Ventricular tachycardia
4. Differential diagnosis of wide QRS
tachycardias
5. Ventricular Fibrillation
6. Asystole
ECG Diag 4/ghazi

1. Premature Ventricular Complexes (PVCs)

Premature ventricular contractions result from an
irritable ectopic focus in the ventricles. This
initiates an early beat.
It may be:
unifocal,
multifocal
multiformed.

ECG Diag 4/ghazi

Single unifocal PVC

ECG Diag 4/ghazi

Multifocal PVC
Multifocal PVCs have
different sites of origin

ECG Diag 4/ghazi

Multiformed PVCs
Usually have the same coupling
intervals (because they originate in the
same ectopic site but their conduction
through the ventricles differ.

Multiformed PVCs are common in digitalis intoxication.

ECG Diag 4/ghazi

Bigeminy and Trigeminy

ECG Diag 4/ghazi

Couplets (2 PVCs in a row):

ECG Diag 4/ghazi

VT after PVC

ECG Diag 4/ghazi

Time of PVCs
1- early in the cycle (R-on-T phenomenon),
2-after the T wave
3- late in the cycle - often fusing with the
next QRS (fusion beat).

ECG Diag 4/ghazi

R on T Phenomenon

ECG Diag 4/ghazi

Interpolated PVC.

If a PVC occurs early enough (especially if the heart

rate is slow), it may appear sandwiched in between
two normal beats
ECG Diag 4/ghazi

Interpolated PVC

ECG Diag 4/ghazi

Fusion Beats
The ventricular contraction from the
ectopic focus occurs at the same
time with the contraction from the
beat transmited from the atrium.
This contraction will appear with a
P wave but a broad QRS complex
and inverted T wave.

ECG Diag 4/ghazi

Recognizing Aberrant Conduction

or PVCs
Aberrant Conduction
Preceding P wave
Initial portion of QRS
identical to conducted
beats
RBBB pattern
No compensatory pause

PVC
No preceding P wave
Monophasic QRS
Big-R, little-R pattern
Compensatory pause

ECG Diag 4/ghazi

Ventricular Escape Complex

If the sinoatrial node slows down
and a focus in the ventricles takes
over control of the heart, the beat is
described as a ventricular escape
complex

ECG Diag 4/ghazi

Accelerated Ventricular Rhythms

Ventricular rate 60-100 bpm
Sometimes called isochronic ventricular rhythm
because the ventricular rate is close to underlying
sinus rate

May begin and end with fusion beats

Usually benign,.

ECG Diag 4/ghazi

Accelerated Ventricular Rhythms

ECG Diag 4/ghazi

Ventricular Tachycardia
Defined as five or more ventricular
ectopic beats in rapid succession.

Signs of myocardial irritability can precede ventricular tachycardia,

like frequent PVCs, couplets, or an R on T phenomenon.

ECG Diag 4/ghazi

Ventricular Tachycardia

Rate?
Regularity?
P waves?

160 bpm

PR interval?

none
wide (> 0.12 sec)

regular
none

QRS duration?
ECG Diag 4/ghazi

Ventricular Tachycardia
Sustained (lasting >30 sec) vs. nonsustained
Monomorphic (uniform morphology) vs.
polymorphic vs. Torsade-de-pointes
Presence of AV dissociation (independent atrial
activity) vs. retrograde atrial capture
Presence of fusion QRS complexes (Dressler
beats)
ECG Diag 4/ghazi

Non-sustained VT

ECG Diag 4/ghazi

Sustained Ventricular Tachycardia

ECG Diag 4/ghazi

Types and causes of VT

VT with ischemic heart disease ('ischemic VT')
VT with structural heart disease - dilated
cardiomyopathy, HCM, MV prolapse
VT without structural heart disease ('idiopathic VT')
Idiopathic right VT : RVOT origin
Idiopathic left Ventricular Tachy.
Bundle branch reentrant tachy.
Arrhythmogenic right ventricular dysplasia( ARVD)
Long QT syndrome (congenital or acquired)
ECG Diag 4/ghazi

Torsade de Pointes
a distinctive VT in which the
QRS complexes change in
morphology from positive to
negative and appear to twist
around an imaginary base line

ECG Diag 4/ghazi

Ventricular Fibrillation
Rate?
Regularity?
P waves?

none

PR interval?

none
wide, if recognizable

irregularly irreg.
none

QRS duration?
ECG Diag 4/ghazi

Asystole
Asystole must be confirmed in 2 leads on
the ECG because it may resemble fine: vfib. Always look at a second lead for
confirmation.
Just make sure the leads have not fallen off
the patient.

ECG Diag 4/ghazi

ASYSTOLE

ECG Diag 4/ghazi

Wide QRS tachycardia

Differential diagnosis

ECG Diag 4/ghazi

Wide QRS Complex Tachycardia

SVT including AF, AFL and AT with
preexisting aberrant conduction (BBB)
SVT including AF, AFL and AT with
functional or rate related aberrant cond.
AF, AFL and AT with AP
Antidromic AVRT
Bundle Branch Reentry
Ventricular Tachycardia
ECG Diag 4/ghazi

Differential diagnosis of wide QRS tachycardia

(1)
Useless guidelines
Symptoms
Haemodynamic disturbances
Regular rhythm

ECG Diag 4/ghazi

Differential diagnosis of wide QRS tachycardia

(2)
Useful guidelines
1. Clinical circumstances
2. Independent atrial activity:
A.direct sign - normal P wave
B.indirect signs: capture beat and fusion beat

3. Ectopic beat: if QRS during tachycardia is

similar to the one of PVB during Sinus R
4. Configuration of QRS in lead V1 or V6
ECG Diag 4/ghazi

Differential diagnosis of wide QRS tachycardia

1. Clinical circumstances
(simple bedside clues to ventricular tachycardia)

Advanced heart disease

Cannon 'a' waves in the JVP
Variable intensity of the S1 heart sound at the
apex (mitral closure)

ECG Diag 4/ghazi

Differential diagnosis of wide QRS tachycardia

2. Independent atrial activity

(strongly suggests VT)
direct sign - normal P wave
AV Dissociation
indirect signs: capture beat and fusion
beat

ECG Diag 4/ghazi

Differential Diagnosis of Wide QRS

Tachycardias
4. Configuration of QRS in lead V1 or V6
( the followings are in favour of VT):
Bizarre QRS axis (i.e. from +150 degrees to -90
degrees ) suggests VT
Especially wide QRS complexes (>0.16s)
Positive or negative Concordance (If all the QRS
complexes from V1 to V6 are in the same direction)

ECG Diag 4/ghazi

Example of VT with positive concordance

ECG Diag 4/ghazi

Example of VT with negative concordance

ECG Diag 4/ghazi

Facts favouring VT
80- 90 % of wide QRS complex tachycardia is VT
Aberrant conduction ( functional or rate related) is
rare especially if tachycardia persists
Presence of Capture or fusion beats
Previous ECG helps for preexisting BBB or PVB
For safety each wide QRS complex tachycardia is
VT until proved otherwise

ECG Diag 4/ghazi

Tachyarhythmias
Narrow complex
Regular

ST
AT
SVT
AFL

Wide complex

Irregular
AF

Regular

VT

MAT
AFL /AT with
variable AV
conduction
ECG Diag 4/ghazi

SVT
With aberrant
conduction

Irregular

AF with
accessory
pathway

ECG Diag 4/ghazi