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Brugada Criteria
SN 66%, SP 98% SN 82%, SP 98%
SN 21%, SP 100%
SN 98.7%, SP 96.5%
Circulation 1991;83:1649-1659
Brugada Criteria
Brugada Criteria
R only
S only
Brugada Criteria
Brugada Criteria
Brugada Criteria
- RBBB : Lead I terminal broad S wave : V1 rsR or notched monophasic R with notching on ascending limb of R wave - LBBB : Lead I monophasic R only! : V1 : dominant S wave with rapid, un-notched descending limb
Evans, G.T. Practical ECG interpretation, 1998
- For RBBB-type complexes : Is there an rSR morphology in V1? : Is there an RS complex in V6 (small septal q OK)? : Is the R/S ratio in V6 > 1? - For LBBB-type complexes : Is there an rS or QS complex in V1 and V2? : Is the onset of the QRS to the nadir of the S in V1 < 70ms? : Is there an R wave in lead V6 without a Q? - Any No result in a default to VT - For VT : sensitivity ~ 90%; specificity ~ 75%
Griffith et al, Lancet 1994;343:386-388
Brugada Criteria
qR pattern
Brugada Criteria
QS waves in V6
Brugada Criteria
QS waves in V6
qR complex in V6
Vereckei Algorithm
SN 10.1%, SP 100% SN 39.6%, SP 97.1%
SN 74.7%, SP 83.3%
SN 70%, SP 89.4%
Vereckei Algorithm
Vereckei Algorithm
Vereckei Algorithm
Vereckei Algorithm
The vi is measured in that lead where a bi- or multiphasic QRS complex is present and the initial ventricular activation is the fastest, and in that particular lead that QRS complex is chosen for the measurement of vi and vt where the onset and end of the QRS are clearly visible.
Vereckei Algorithm
SN 19.9%, SP 95%
SN 90.7%, SP 87.5%
- During SVT w/ BBB, the initial rapid septal activation and the later main ventricular activation wavefront move away from lead aVR, creating a negative QRS complex in lead aVR ; Exception to this generalization is occurs in inferior myocardial infarction where there is the loss of the initial inferiorly directed forces creating an initial r wave (rS complex) during NSR or SVT - Because an initial dominant R wave in aVR is incompatible w/ SVT, its presence suggest VT, typically originating from the inferior or apical region
the inferior or apical wall, but would not show an initial R wave in aVR - Would rather show a slow, initial upward vector of variable size pointing toward aVR even if the main vector of the VT points downward and creates a predominately negative QRS in lead aVR
- Exceptions would be VT originating from the most basal sites of the interventricular septum or free wall
Sasaki Criteria
Step 1: Initial R in aVR?
Step 2: In any precordial lead, is the interval from onset of R-wave to the nadir of the S 100 msec (0.10 sec)? Step 3: Initial r or q 40 ms in any lead?
Sasaki Criteria
Circulation 2009;120:S671
SN & SP for VT diagnosis : 86% and 67% by Brugada algorithm, 76% and 86% by Vereckei algorithm, and 86% and 53% by aVR algorithm AV dissociation had a low sensitivity (7%) and the assessment of bundle branch block morphology showed innegligible interobserver variation (10 to 20% by 3 independent observers). The step with sensitivity 30% and specificity 90% for diagnosing VT included longest RS 100 msec (sensitivity, 37%; specificity, 97%), initial R in aVR (39% and 100%), and Vi/Vt 1.0 (49% and 90%) Evaluating Vi/Vt 1.0 indicative of slow initial ventricular activation in VT is complicated. We measured the duration of the initial r or q of any lead of WCTs and validated it. The duration was 5527 msec in VT and 275 msec in SVT (P <0.05). Receiver operating curve revealed 40 msec as a cutoffpoint which showed 86% sensitivity and 97% specificity for diagnosing VT, both of which were greater than those of Vi/Vt 1.0. The accuracy of this new algorithm (86%) was superior to those of Brugada (79%), Vereckei (79%) and aVR (75%) algorithms (all P<0.05).
- In RBBB-like WCT, duration > 140 msec suggests VT - In LBBB-like WCT, duration > 160 msec suggests VT - QRS duration > 160 msec is a strong predictor of VT regardless of BBBM ; Except in cases of SVT w/ an AV accessory pathway and the presence of drugs capable of slowing intraventricular conduction (such as class 1a or class 1c or amiodarone) - QRS duration < 140 msec does not exclude VT ; VT originating from the septum or w/ in the His-Purkinje system
complexes) (90% specificity for VT) - positive : all entirely positive w/ tall, monophasic R ; most often d/t VT but can also occur in rare cases of antidromic AVRT w/ a left posterior accessory pathway - Negative concordance All entirely negative w/ deep monophasic QS complexes
Concordance
Positive Concordance
V-A conduction
Echo Beat
Quiz 1.
Quiz 1.
AVNRT with LBBB
Typical LBBB morphology No positive Brugada criteria
Quiz 2.
Quiz 2.
Monomorphic VT
Although there is a broad complex tachycardia (HR>100,
QRS>120), the appearance in V1 is more suggestive SVT with aberrancy, given that the complexes are not that broad(<160 ms) and the right rabbit ear is taller than the left. However, on closer inspection there are signs of AV dissociation, with superimposed P waves visible in V1. Also, the presence of a northwest axis and an R/S ratio < 1 in V6 (tiny R wave, deep S wave) indicate that this is VT.
Quiz 3.
Quiz 3.
Sinus tachycardia with incomplete RBBB
P waves are visible before each QRS complex There is a typical RBBB morphology with a RSR complex
in V1 and wide S wave in the lateral leads I, V5-6. In contrast to the previous example, there is a dominant R wave in V6 (RS ratio > 1), which is much more typical of RBBB QRS complexes are only slightly prolonged (110 ms), making this an incomplete RBBB. Q waves and T-wave inversions in III and aVF suggest prior inferior infarction.
Quiz 4.
Quiz 4.
Tricyclic antidepressant toxicity
QRS complexes are very broad (~200ms) however,
unlike with VT most of the broadening is in the terminal portion of the QRS (this can be best appreciated in leads V3-6 where narrow R waves are followed by massively broad and deep S waves). There are no positive Brugada criteria in particular, the RS interval is < 100 ms. No P waves can be seen
Quiz 5.
Quiz 5.
AVRT
5 year-old boy This is the one rhythm that may be impossible to
distinguish from VT In this case the main clue is the history more thant 95% of broad complex tachycardias in children are SVT with aberrancy
Quiz 6.
Quiz 6.
Rapid ventricular paced rhythm
There are obvious pacing spikes before each QRS
complex Ventricular paced rhythms have features in common with other ventricular rhythms in this case the ECG demonstrates negative concordance in V1-6, initial R wave > 40 ms in V1, RS interval > 70 ms in V1, QS complex in V6
Vereckei Algorithm
Vereckei Algorithm